随着医保领域打击欺诈骗保力度的加大,医保骗保行为呈现出实施主体多元、手段专业多样、行为隐蔽复杂、社会危害加重等特征,导致医保基金监管难度加大,存在打击欺诈骗保取证侦查难、追赃挽损难、多环节复杂主体打击难等问题。为破解这些难点,更好地维护基金使用安全,本文从多主体协同治理与风险预防为核心的敏捷预防治理理论着手,构建多主体协同预防治理模式,以期促进医保基金持久稳健运行。
Abstract
With the increasing efforts to crack down on medical insurance fraud in the medical insurance field, the behavior of medical insurance fraud presents characteristics such as diverse implementation subjects, various professional methods, hidden and complex behaviors, and increased social harm, resulting in the increased difficulty of regulating medical insurance fund. There are many problems, such as difficulties in evidence collection and investigation, difficulties in recovering stolen goods and losses, and difficulties in cracking down on complex entities in multiple links. In order to solve the problems and further maintain the medical insurance fund security, this paper starts with the agile prevention and governance theory with multi-agent collaborative governance and risk prevention as the core, constructs a multi-subject collaborative prevention and governance model, to promote the sustainable and stable operation of the medical insurance fund.
关键词
医保骗保 /
情境预防 /
敏捷预防 /
协同治理
Key words
medical insurance fraud /
situational prevention /
agile prevention /
collaborative governance
{{custom_sec.title}}
{{custom_sec.title}}
{{custom_sec.content}}
参考文献
[1] 姚强,杨菲,郭冰清.基本医疗保险“欺诈骗保”现象的影响因素及路径研究——基于我国31个省级案例的清晰集定性比较分析[J].中国卫生政策研究,2020,13(11):24-31.
[2] 马蔚姝,张再生.医疗保险市场中骗保行为产生的经济学分析[J].现代经济探讨,2008(11):46-49.
[3] 刘汴鹤. 医保骗保行为的刑法适用问题研究[J].医学与法学,2023,15(4):9-20.
[4] 黄冠. 基础医疗保障骗保行为视角下的中美比较分析[J].四川行政学院学报,2017(4):86-90.
[5] 陈起风. “救命钱”沦为“唐僧肉”:内在逻辑与治理路径——基于百余起骗保案的实证研究[J].社会保障研究,2019(4):42-51.
[6] 王丽丽.为依法惩治医保骗保犯罪提供明确法律政策指引[N].人民法院报,2024-03-02.
[7] 姜懿容,孟彦辰.我国欺诈骗保犯罪法律规制研究[J].中国医疗保险,2023(1):70-74.
[8] 陈柄臣,李良才.医保诈骗犯罪实证研究[J].浙江警察学院学报,2023(1):81-89.
[9] 裴颖. 医保“个人账户”去留问题的探讨[J].人口与经济,2008(3):65-70.
[10] 薛新东,赵曼.医保个人账户低效率的经济学分析[J].中国卫生经济,2007(9):73-75.
[11] 韩成芳. 医疗人工智能领域个人健康数据保护的困境及其破解[J].科技与法律(中英文),2024(1):54-60.
[12] 谢小剑. 行政犯“行刑衔接”困境破解:从分离式到联动式[J].中国法学,2024(2):287-304.
[13] 练育强. 行政执法与刑事司法衔接制度沿革分析[J].政法论坛,2017,35(5):167-175.
[14] 王文松. 医保骗保犯罪案件侦查难点与侦查进路[J].中国医疗保险,2024(4):28-34.
[15] 施文凯,聂玉亮,张小娟.整体性治理视角下的新加坡医疗保险治理体系及对我国的启示[J].中国卫生政策研究,2020,13(4):10-16.
[16] MERGEL I, GANAPATI S, WHITFORD A B.Agile: a new way of governing[J]. Public administration review, 2021, 81(1): 161-165.
[17] 袁桂娟,薛怀祖.情景预防视阈下城市轨道交通公共安全治理研究[J].都市快轨交通,2021,34(4):154-159.
[18] GUERETTE R T, BOWERS K J.Assessing the extent of crime displacement and diffusion of benefits: a review of situational crime prevention evaluations[J]. Criminology, 2009, 47(4): 1331-1368.
[19] HO H, KO R, MAZEROLLE L.Situational crime prevention (SCP) techniques to prevent and control cybercrimes: a focused systematic review[J]. Computers & security, 2022, 115: 102611.
[20] GILMOUR N.Preventing money laundering: a test of situational crime prevention theory[J]. Journal of money laundering control, 2016, 19(4): 376-396.
[21] HOLT T J, GRIFFITH M, TURNER N, et al.Assessing nation‐state‐sponsored cyberattacks using aspects of situational crime prevention[J]. Criminology & public policy, 2023, 22(4): 825-848.
[22] 张淑瑛. 基于情境预防理论的农村基层腐败犯罪预防机理与路径选择[J].理论导刊,2020(5):85-91.
[23] 索斯奈杰尔,布里斯曼阿维,倪铁,等.环境犯罪整体预防机制论略[J].青少年犯罪问题,2018(1):104-114.
[24] 迟舜雨,杜安琪.生成式人工智能敏捷治理的国际趋势与建构模式[J].智能科学与技术学报,2024,6(3):402-412.
[25] 雷咸胜. 我国医保基金监管现存问题与对策[J].中国卫生经济,2019, 38(8):31-33.
[26] 张广田. 隐瞒第三方责任骗取医保基金问题探讨[J].中国医疗保险,2024(10):62-67.
[27] 王泽坤,杭富云,闫鹰,等.某三甲医院意外伤害医保稽查审核流程优化分析[J].湖北医药学院学报,2020,39(4):416-418.
[28] 詹长春,黄晶晶.协同治理视角下医保欺诈行为监管体系优化研究[J].中国卫生事业管理,2021,38(9):668-671.
[29] 丁峰,陈华,许宝洪.张家港基本医保引入第三方监管服务的实践初探[J].中国医疗保险,2020(2):41-43.
[30] 阳义南,肖建华.医疗保险基金欺诈骗保及反欺诈研究[J].北京航空航天大学学报(社会科学版),2019,32(2):41-51.
[31] 郭莺,茅雯辉,向浩,等.韩国医疗保险监管组织体系和管理能力及其启示[J].中国卫生政策研究,2020,13(3):1-5.
