| 摘要: |
| 医疗保险违规欺诈行为监管是各国政府部门和医疗保险管理机构面临的共同问题，从监管主体、监管对象、监管内容、监管工具和监管依据等方面对不同医疗卫生体制模式，国家关于定点医疗机构医保违规欺诈行为监管的做法和经验进行比较分析。结果显示，扩大医疗保险项目覆盖范围是监管医疗机构的基础，混合付费体系是监管医疗机构的重要制度工具，卫生行政部门在医疗机构监管中发挥着重要的作用，政府主导的监管模式是主流的监管模式，应注重按过程监管的全方位监管方式，健全的法律法规和惩处机制是有效控制欺诈骗保行为的重要保障，信息系统的建立和完善是有效和快速地识别系统内不合理或异常支付的有效手段。 |
| 关键词: 医疗机构 医保违规行为 监管 |
| DOI： |
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| 基金项目: |
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| International Experiences and Revelation on the Regulation of the Medical Insurance Fraud by the Medical Institutions |
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| Abstract: |
???? The regulation on the medical insurance fraud is the common issue faced by both governments and medical insurance companies in every country. It compared and analyzed the practices and experiences from countries that have different health systems on the regulation of the medical insurance fraud from the perspective of the regulation body, targets, contents, tools and basis. The results have showed that expanding the health insurance coverage is the basis to regulate the medical insurances; mixed payment system is the important system tool for the supervision; health administrative departments plays a vital role in the regulation, the government-led regulatory is the mainstream mode; the process-based regulation should be paid more attention to; sound laws and regulations and punishment mechanism are important guarantees for controlling the fraud behavior effectively, and establishing and improving the information system is the effective way to identify the unreasonable or unusual payments promptly. |
| Key words: medical institution, medical insurance fraud behavior, regulation |
