医保基金作为保障公民健康权益的“救命钱”,其安全可持续运行直接关系医疗保障制度的公平性与民生福祉。在医保信息化建设提速、监管力度持续强化的背景下,骗保行为呈现出主体角色嬗变、作案链路合谋化、手段技术化等新特征,对基金安全构成严峻挑战。通过对江苏省公开通报的骗保典型案例研究,系统剖析骗保行为的内在逻辑新图景,探究制度缺陷与管理漏洞等滋生诱因,并从枢纽管控、漏洞堵塞、监管效能提升、长效机制健全四个维度,提出“激励重塑—技术赋能—协同联动—生态优化”的系统治理路径,为筑牢医保基金安全防线提供实证参考与实践指引。

As the "lifeline funds" safeguarding citizens' health rights, the secure and sustainable operation of medical insurance funds is directly tied to the fairness of the healthcare system and public well-being. Against the backdrop of accelerating medical insurance informatization and strengthened regulatory efforts, fraudulent insurance activities have exhibited new characteristics, including shifts in perpetrator roles, collusion in criminal chains, and technologically sophisticated methods, posing severe challenges to fund security. Through a study of publicly reported typical cases of medical insurance fraud in Jiangsu Province, this paper systematically analyzes the emerging internal logic of fraudulent behaviors, explores underlying causes such as institutional flaws and management gaps, and proposes a systematic governance framework from four dimensions of hub control, vulnerability mitigation, enhanced regulatory effectiveness, and long-term mechanism improvement. This framework follows a "incentive restructuring-technology empowerment-collaborative linkage-ecosystem optimization" approach, providing empirical reference and practical guidance for fortifying the security of medical insurance funds.