With the continuous improvement of the outpatient mutual-aid mechanism, the coverage and guarantee of the medical insurance fund is constantly expanding. However, at the same time there are new fraudulent behaviors of medical insurance funds, posing threats and challenges to the safe operation of medical insurance funds. This study is based on the outpatient cases which medical insurance refuses to pay for in a tertiary hospital in Beijing from January 2017 to September 2022, and applies expert consultation, literature review, and in-depth interviews to construct the risk event database for outpatient medical insurance funds. On this basis, attribution analysis is used to analyze the causes of medical insurance fraud, laying the foundation for precise regulation of medical insurance fund.
Key words
outpatient mutual-aid /
supervision of medical insurance fund /
risk events related to the use of medical insurance funds /
attribution analysis
{{custom_sec.title}}
{{custom_sec.title}}
{{custom_sec.content}}
References
[1] 杨燕绥,李超凡,于淼,等.医保筹资与职工医保个人账户权益置换改革[J].中国医疗保险,2020(08):10-16.
[2] 国家医疗保障局.2022年医疗保障事业发展统计快报[R/OL].(2023-03-09)[2023-05-18].http://www.nhsa.gov.cn/art/2023/3/9/art_7_10250.html.
[3] 朱铭来,郑先平.关于建立健全职工医保门诊共济保障机制的思考[J].中国医疗保险,2020(10):6-10.
[4] 付晓光,万泉,柴培培,等.我国职工医保门诊保障的现状及改革思考[J].中国医疗保险,2021(06):36-38.
[5] 黄华波. 加强医保基金监管和打击欺诈骗保工作的思考[J].中国医疗保险,2019(03):32-35.
[6] 刘静,黄镇,覃肖潇,等.基于故障树分析法的医保基金使用风险识别研究——以某市医保基金监管真实世界数据为例[J].中国医疗保险,2019(05):34-38.
[7] 江小州. 金华市推行门诊“APG点数法”付费改革的探索与实践[J].中国医疗保险,2021(08):49-52.
[8] 朱旭林,龚熠,郭丽娟,等.医保基金监管的方式、成效与困境[J].卫生经济研究,2021(09):49-52.
[9] 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(08):31-33.
[10] 刘佳玉,王欣,孙晶晶,等.医疗机构医保智能审核系统的设计与应用[J].中华医院管理杂志,2022(02):97-100.
