美国医疗保险反欺诈项目现状及其对我国的启示

The status quo of health care anti-fraud programs in the United States and its enlightenment to China

美国公共医保欺诈问题严重,为此美国开展了一系列反欺诈活动。其中医疗保险欺诈和滥用控制(Health Care Fraud and Abuse Control,简称HCFAC)项目是美国政府反欺诈工作的一大亮点。文章以HCFAC项目为研究对象,简要介绍了项目成立背景、机构设置、反欺诈措施与法律依据等基本情况,通过对美国医保欺诈案例的变化形势与HCFAC反欺诈工作发展的分析,总结了HCFAC项目的特点。提出我国可以适当借鉴HCFAC的成功经验,完善反欺诈法律制度、建立专门的医保反欺诈机构、引入社会力量参与和建立全国性医保大数据共享反欺诈平台,进一步打击欺诈骗保行为,保障医保基金安全等建议。

The serious problems of public health care fraud in the United States have led to a series of anti-fraud activities.Health Care Fraud and Abuse Control(HCFAC)program is a highlight of the American government's anti-fraud work.The article takes HCFAC program as the object of study,and briefly introduces the background of the program's establishment,institutional setup,anti-fraud measures and legal basis,etc.Through the analysis of the changing situation of health care fraud cases in the U.S.and the development of HCFAC's anti-fraud work,it summarizes the characteristics of the HCFAC program.It proposes that China can appropriately learn from the successful experiences of HCFAC to improve the legal system of anti-fraud,establish a special health care anti-fraud agency,introduce social forces to participate in the establishment of a national anti-fraud platform of sharing of healthcare big data,further crack down on insurance fraud and protect the security of medical insurance funds.