With the continuous promotion of DRG/DIP payment reform, the newly emerged illegal use of medical insurance fund such as upcoding is becoming more prominent, and there is no corresponding expression and definition of these behaviors in The Regulations on the Supervision and Administration of the Use of Healthcare Security Funds (hereinafter referred to as The Regulations). There is no scientific, unified, and operable practical standard nationwide on the basis, solution, and loss assessment of these violations. Therefore, this paper focuses on the issues existed in identification and treatment of hospitals' violations under DRG/DIP payment, explains the one-to-one correspondence among the violations and the specific items in The Regulations, and discusses the accurate way to determine the damage to the healthcare security fund under DRG/DIP payment, which provides theoretical basis for further improving the administrative law enforcement ability of the healthcare security department and the refined management of the healthcare security fund.
Key words
DRG /
DIP /
payment reform /
regulation of violations /
loss assessment of healthcare security fund
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