目的: 探讨医保参保人违规违法现象的行为表现、产生逻辑和治理路径,为有效加强医保基金监管治理提供建议。方法: 运用案例分析、社会网络分析对医保参保人的违规案例进行研究。结果: 184起案例中,伪造虚假证明材料最多,共计79起;冒用盗刷医保卡51起;捏造扭曲医疗事故事实36起。在治理路径中,以地方医保部门检查发现为主,群众举报亦是重要发现途径;追回医保资金、移交公安部门是主要处理结局,《刑法》和《社会保险法》是主要处理依据。结论: 应加快推动医疗保险信息平台建设,促进多部门协同治理违规违法现象;有效落实群众举报奖励机制,加大曝光力度;提高参保人法律观念、道德水平,避免非合理化认知心态盛行。

Objective: This paper explores the behavioral performance, the generation logic, and the governance path of the insured's medical insurance violations to provide suggestions for the effective supervision of medical insurance funds. Methods: Case analysis and social network analysis were used to analyze cases of medical insurance violations implemented by the insured. Results: Among the 184 cases, the insured were involved in 79 cases of forging false materials, 51 cases of fraudulent use of medical insurance cards, and 36 cases of fabricated medical malpractice facts. As to the governance path, the inspection by the local medical insurance department is the main method, and mass reporting is also an important discovery approach. Recovering medical insurance funds and handing over to the public security department are the main processing outcomes. The Criminal Law and the Social Insurance Law are the main processing basis. Conclusion: The construction of the medical insurance information platform should be further promoted, and the multi-departmental coordination of governance against violations of laws and regulations should be accelerated. The public reporting and reward mechanism should be effectively implemented, and publicity and exposure should be increased. Finally, the legal concept and moral level of the insured should be improved to avoid the prevalence of irrational cognitive mentality.