以按疾病诊断相关分组(diagnosis related group,DRG)付费改革为切入点,剖析我国医保欺诈及其防治现状,总结DRG付费中我国医保欺诈防治存在的主要挑战,并提出具体对策建议.研究表明,DRG付费中我国医保欺诈防治存在DRG付费改革及其配套监管制度亟待完善、DRG付费改革可能会强化医疗机构的医保欺诈动机、DRG付费中我国医保欺诈防治的法律依据相对滞后以及公众对DRG付费改革相关内容认知不足等挑战.建议应加快完善DRG付费改革及其配套监管制度;促进医疗机构公益性与盈利性均衡发展;强化医保欺诈防治法律监管制度与协同治理机制;加大医保欺诈防治宣传及惩罚力度.
The Challenges and Countermeasures of Medical Insurance Fraud Prevention under DRG Payment in China
This study takes the diagnosis related group(DRG)payment reform as a starting point to delve into the current situation of medical insurance fraud and its prevention in China.It summarizes the main challenges in combating medical insurance fraud under DRG payment and proposes specific countermeasures and suggestions.The research indicates that challenges include the urgent need to improve the DRG payment reform and its accompanying regulatory system,potential reinforcement of medical institutions'motives for medical insurance fraud under DRG payment,delays in the legal frameworks for addressing medical insurance fraud in China,and the public's limited understanding of the reform.Recommendations include accelerating the refinement of the DRG payment reform and its accompanying regulatory system,promoting a balanced development of public welfare and the profitability of medical institutions,strengthening legal supervision and collaborative governance mechanisms for preventing medical insurance fraud,and enhancing public awareness and the penalties for medical insurance fraud.
medical insurance frauddiagnosis related groupfund supervision
NETL
NSTL
万方数据
