目的: 通过分析医务人员与患者对骗保行为的认知情况、原因及防范措施,为完善医保基金监管制度提供建议。方法: 在理论与文献基础上,设计医务人员与患者调查问卷,选取北京某综合性三甲医院进行现场调研,共收回300份有效问卷,分析医务人员与患者的骗保认知差异。结果: 医患双方对骗保行为缺乏认知,经归类分析后,骗保行为包括主观故意骗保和客观过失骗保,骗保原因是认知缺乏与决策偏差,罚款、取消定点医疗机构资格是医患双方对骗保防范措施的共同看法。结论: 加强骗保知识宣传教育,提高医患双方对骗保行为的认知度,减少客观过失骗保行为;以法律为准绳,严厉打击主观故意骗保行为;利用信息化统一平台,建立智慧医保,提高医保监管效能。

Objective: By analyzing the perceptions of medical staff, patients about medical insurance fraud, its causes, preventive measures, the paper provides suggestions for improving the regulatory system of medical insurance funds. Methods: Based on the theory, literature, we designed a questionnaire for medical staff, patients, selected a comprehensive tertiary hospital in Beijing to conduct on-site research.300valid questionnaires were returned to analyze the differences between medical staff, patients' perceptions of medical insurance fraud. Results: There is a lack of cognition of medical insurance fraud between doctors, patients. After categorization, analysis, medical insurance fraud includes subjective intentional fraud, objective negligent fraud, the causes of medical insurance fraud include a lack of cognition, decision bias, fines, cancellation of designated medical institutions are consensus on medical insurance fraud prevention measures between doctors, patients. Conclusion: We should strengthen the publicity, education of medical insurance fraud knowledge, improve the awareness of fraudulent behavior of both doctors, patients, eliminate objective negligent fraud. Meanwhile, we should take the law as the criterion to crack down on intentional fraudulent behavior, use the unified platform of information technology to establish intelligent medical insurance, improve the effectiveness of medical insurance supervision