近年来医保基金欺诈事件屡屡见诸媒体,逐渐成为舆论焦点。本研究基于扎根理论研究方法,借助NVivo12 Plus质性分析软件,从国家医疗保障局2019年-2022年曝光的医保基金欺诈案例中选取100个进行分析,全方位检视当前医保基金欺诈景象,从而发现并总结出我国现阶段医保基金欺诈治理面临的主要挑战。借鉴国内外反欺诈治理措施,提取相关反欺诈经验,在社会治理理论基础上搭建出集“政府、非政府组织、医疗服务供方、医保机构、医疗服务需方”为一体的“五位一体医保基金反欺诈体系”,探索中国特色的医疗保障基金反欺诈路径,为进一步完善医疗保险反欺诈工作提出建议,以应对当前日益严峻的欺诈骗保形势,确保中国特色基本医疗保障制度平稳运行。

In recent years, medical insurance fund fraud incidents have repeatedly appeared in the media and gradually become the focus of public opinion. Based on the Grounded Theory research method, with the help of NVivo12 Plus qualitative analysis software, 100 cases of medical insurance fund fraud exposed by the National Healthcare Security Administration from 2019 to 2022 were selected for analysis, and the current medical insurance fund fraud scene was comprehensively examined so as to discover and summarize the main challenges of medical insurance fraud governance in China. Drawing on anti-fraud governance measures at home and abroad, extracting relevant anti-fraud experience, and on the basis of social governance theory, we have built a "five-in-one medical insurance fund anti-fraud system" that integrates "government, non-governmental organizations, medical service providers, medical insurance institutions, and medical service buyers", explored the anti-fraud paths of medical insurance fund in line with Chinese characteristics, and made suggestions for further improving the anti-fraud work of medical insurance, so as to cope with the current increasingly severe situation of medical insurance fraud, and ensure the smooth operation of the basic medical security system with Chinese characteristics.