医保基金信用监管体系（以下简称医保信用体系）建设是保障医保基金安全、促进医保事业健康发展及营造全社会诚信守法良好氛围的重要举措。济南市积极探索建立以全主体参与、全过程覆盖为支撑的标准化、一体化及精细化医保信用体系,通过构建多维度信用评价体系对定点医药机构进行综合评价。本研究从医保信用评价理论基础出发,以2023年度定点医疗机构评价结果的截面数据为研究样本,结合济南市医保信用评价指标体系的构建及实践情况,对现行体系中显现的问题进行系统梳理与深入剖析。最终从医保信用体系的优化、形成社会共治的监管合力两个角度出发提出可行性建议。

The construction of the credit supervision system for medical insurance fund (hereinafter referred to as medical insurance credit system) is an important measure to ensure the safety of medical insurance funds, promote the healthy development of the medical insurance undertaking, and create a favorable atmosphere of integrity and law-abiding in the society. Jinan City has actively explored the establishment of a standardized, integrated and refined medical insurance credit system supported by full coverage of all subjects and the whole process, and conducted comprehensive evaluations of designated medical and pharmaceutical institutions through the construction of a multi-dimensional credit evaluation system. Starting from the theoretical basis of medical insurance credit evaluation, this study takes the cross-sectional data of the evaluation results of designated medical institutions in 2023 as the sample, and combines the construction and practice of Jinan's medical insurance credit evaluation index system to systematically analyze the problems manifested in the current system. Finally, feasible suggestions are proposed from the two perspectives of optimizing the medical insurance credit supervision system and forming the joint force for social co-governance.