合作治理视角下的医疗保险反欺诈机制:国际经验与启示

随着我国社会保险事业的快速发展,医疗保险欺诈现象也不断增多,严重威胁到医疗保险基金和医保制度的稳健运行。作为保险欺诈"重灾区"的欧美国家,在反医疗欺诈措施方面积累了不少经验,特别是政府与市场的相互配合,医保反欺诈取得显著成效。文章论述了国外医疗保险反欺诈机制,得出建立医疗保险反欺诈机构、充分发挥非营利组织的补充作用、加强对医疗和医保机构欺诈的制约与监管、利用现代信息技术提高反欺诈水平等启示。

Medical insurance anti-fraud mechanism from the perspective of cooperative governance:International experience and implications

With the rapid development of China''s social insurance, the phenomenon of medical insurance fraud is also increasing, which seriously threatens the comprehensive operation of health insurance funds and medical insurance system. Because of the cooperation between the government and the market, Europe & US have accumulated a lot of experience and achieved considerable success in anti-medical fraud as the "harder-hit area" in insurance fraud. This paper discusses the anti-fraud mechanism of foreign medical insurance to establish medical anti-fraud agencies within the government, and give full play to the complementary role of non-profit organizations to strengthen the control and supervision of medical insurance and health care institutions and uses modern information technology to improve anti-fraud level.