目的: 了解参保人违法违规行为倾向,甄别其影响因素,为针对性治理参保人违法违规行为提供参考。方法: 基于欺诈菱形理论模型,对733名参保人开展问卷调查,采用一般描述性统计、单因素分析和多元线性回归等对参保人违法违规行为倾向进行分析研究。结果: 参保人的医保违规倾向总体水平为1.47分±1.356分,医保违规倾向较高的受访者占25.37%。医药行业存在潜规则这一机会诱因（β=0.107）,参保人的身体健康压力（β=0.148）、外借社保卡是助人行为（β=0.189）和医保违规不会被发现和处罚（β=0.107）等自我合理化因素,以及在医疗—医药—医保系统认识熟人（β=0.157）和具备作案条件、渠道和工具（β=0.147）等能力因素,均对参保人违法违规行为倾向有显著影响。结论: 加强多部门协作和智能监管,提升参保人的身体健康水平,推进医保法治和道德教育宣传,纠正参保人的非理性认识,强化医疗服务供方职业道德教育。

Objective: The paper is to understand the insured persons' tendency of medical insurance violations and identify the influencing factors, providing a reference for targeted governance of the insured persons' medical insurance violations. Methods: Based on the fraud diamond theoretical model, a questionnaire survey was conducted among 733 insured persons, and general descriptive statistics, single factor analysis, and multiple linear regression were used to show the insured persons' tendency of medical insurance violations. Results: The overall level of the insured persons' tendency to violate medical insurance regulations was 1.47±1.356 points, and 25.37% of the respondents showed a higher tendency to violate medical insurance regulations. The opportunity incentives of hidden rules exist in the pharmaceutical industry (β=0.107), the health pressure of the insured (β=0.148), the self-rationalization factors of borrowing social insurance cards is helping others (β=0.189) and medical insurance violations will not be discovered and punished (β=0.107), as well as the ability factors of knowing acquaintances in the medical institution-medicine-medical insurance system (β=0.157) and having the conditions, channels and tools to commit crimes (β=0.147) have a significant impact on the insured persons' tendency of medical insurance violations. Conclusion: It is necessary to strengthen multi-sector collaboration and intelligent supervision, improve the health level of the insured, promote the publicity of medical insurance law and moral education, correct the irrational knowledge of the insured, and strengthen the professional ethics of medical service providers.