目的: 分析“十四五”时期医保基金监管的成效与治理转型特征,为“十五五”时期完善监管体系提供参考。方法: 基于国家医疗保障局2021—2025年《全国医疗保障事业发展统计公报》数据,采用描述性统计和趋势分析方法,从追回规模、追回结构、智能监管、刑事打击、制度创新五个维度进行考察。结果: “十四五”期间医保基金追回规模逐年扩大,年度走势呈“前低后高”特征;协议管理是基金挽回的主渠道,占比接近八成;智能监管推动监管关口向事前和事中延伸,事前提醒和事中拒付成效逐步显现;2025年医保支付资格管理制度全面实施,实现了监管对象从机构向个人的延伸。结论: “十四五”时期医保基金监管呈现从事后查处向全链条防控、从机构监管向“机构+人”双重约束、从人工检查向智能筛查与精准打击相结合的转型趋势,多层次监管体系基本形成。但智能监管规则临床维度覆盖不足、支付方式改革下新型违规识别困难、基层监管能力不匹配等问题仍然存在,“十五五”时期需从规则体系完善、支付与监管协同、能力建设等方面持续深化。

Objective: The paper analyzes the effectiveness and governance transformation characteristics of medical insurance fund supervision during the 14th Five-Year Plan period, to provide references for improving the supervision system during the 15th Five-Year Plan period. Methods: Based on data from the National Healthcare Security Administration's Statistical Communiqués on the Development of Healthcare Security Undertakings (2021-2025), descriptive statistics and trend analysis were employed to examine five dimensions: recovery scale, recovery structure, intelligent supervision, criminal enforcement, and institutional innovation. Results: During the 14th Five-Year Plan period, the scale of recovered medical insurance funds expanded year by year, with an annual trajectory characterized by "low in the early years and high in the later years". Agreement management served as the primary channel for fund recovery, accounting for nearly 80%. Intelligent supervision extended the regulatory frontier to pre-event and in-event stages, with the effectiveness of pre-event reminders and in-event payment refusals gradually becoming evident. In 2025, the medical insurance payment qualification management system was fully implemented, extending supervision from institutions to individuals. Conclusion: During the 14th Five-Year Plan period, medical insurance fund supervision exhibited a transformation trend from post-investigation to whole-chain prevention and control, from institutional supervision to the dual constraint of "institutions plus individuals", and from manual inspection to a combination of intelligent screening and targeted enforcement. A multi-level supervision system has largely taken shape. Nevertheless, problems persist—insufficient clinical-dimension coverage of intelligent supervision rules, difficulties in identifying emerging violations under payment method reform, and inadequate grassroots supervision capacity. During the 15th Five-Year Plan period, further efforts are needed to refine the rule system, strengthen coordination between payment and supervision, and enhance capacity building.