医疗反腐背景下定点医药机构欺诈骗保的责任追究研究

Study on the Accountability for Fraud and Insurance Fraud of Designated Medical Institutions in the Context of Medical Anti-corruption

医疗保障领域欺诈违法违规犯罪行为频发,按其行为主体可划分为参保人欺诈和定点医药机构欺诈两种类型,现行法律体系对之存在协议管理、行政监管和刑事制裁三个层次的规制体系,在医疗反腐大背景下更是要求对后一类骗保行为进行有效规制,然而现行刑法规制体系缺乏相应法律依据,行政监管体系也存在法条适用模糊、进而产生行刑衔接难题,故在法院被动执法失灵时行政机关的事前规制便具有必要性;引入企业合规理论中单位犯罪主体关系结构理论及单位归责理论,有助于厘清医疗机构及其组织体成员的责任分配关系,促进准确适用《医疗保障基金使用监管条例》对相应违法行为所作的处罚罚则,也有助于探寻定点医药机构医保基金专项合规的完善路径。

In the field of medical security,fraud,violations and crimes occur frequently,which can be divided into two types according to their subjects:fraud of insured persons and fraud of designated medical institutions.The current legal system has three levels of regulation system,namely agreement management,administrative supervision and criminal sanctions,and requires effective regulation of the latter type of insurance fraud in the context of medical anti-corruption.However,the current criminal law regulation system lacks the corresponding legal basis,and the administrative supervision system also has the ambiguity of the application of law articles,which leads to the difficulty in the execution,so it is necessary for the administrative organs to regulate in advance when the passive law enforcement fails.The introduction of the subject relationship structure theory of unit crime and the responsibility theory of unit in the corporate compliance theory is helpful to clarify the responsibility distribution relationship of medical institutions and their organizational members,promote the accurate application of penalties for corresponding illegal acts in the Regulations on the Use of Medical Security Fund,and also helpful to explore the perfect path for the special compliance of medical insurance funds in designated medical institutions.