美国医疗服务反欺诈的经验与启示

The Experience and Enlightenment of Anti-Fraud in American Medical Services

目的:总结美国医疗服务中的反欺诈经验,以期为我国构建系统高效的医保基金监管体系、提高医保基金使用效率提供经验参考。方法:通过文献研究和归纳总结等方法,总结美国建立医疗服务反欺诈体系的经验与挑战。结果:梳理了美国医疗服务欺诈行为内涵,从法律法规体系、组织体系、全流程监管机制和公众教育四个方面总结了美国医疗服务反欺诈体系建设经验。结论:建议从医疗服务反欺诈法律法规体系建设、加强医疗服务反欺诈顶层设计和部际合作力度、建立多层级医疗服务反欺诈队伍、加强公众医疗服务反欺诈知识宣传教育等角度构建我国医保基金监管体系。

Objective:The paper summarizes the experience of healthcare anti-fraud in the US,in order to provide experience and reference for constructing a systematic and efficient anti-fraud system and improving the efficiency of medical insurance fund utilization in China.Methods:Literature research and inductive generalization methods were used to summarize the experience and challenges of American healthcare anti-fraud system.Results:The healthcare anti-fraud system in the US was summarized from four aspects:legal and regulatory system,organizational system,whole-process supervision mechanism and public education.Conclusion:It is suggested to construct an anti-fraud system in China from establishing a law and regulation system for anti-fraud in medical services,strengthening top-level design and inter-ministerial cooperation,establishing a multi-level healthcare antifraud system,and enhancing public education on healthcare anti-fraud.