天津市H区医保基金骗保问题的研究

发布时间：2018-04-02 21:32

本文选题：社会医疗保险　切入点：骗保表现　出处：《河北工业大学》2014年硕士论文

【摘要】：作为天津市社会保险的重要组成部分，天津市社会医疗保险已走过十多个年头，随着政策的不断调整，，参保群众所享受到的医疗待遇在逐年提高，但是，社会医疗保险中的骗保行为也一直不断出现，仅从天津市来看，每年内部测算骗保金额保守估计都在上亿。这损害了大多数依法合规的医疗机构和参保群众的切身利益，严重影响了医保基金的平稳运转和安全。本文作者在天津市H区负责医疗保险工作多年，参与查办区内区外多起医疗骗保案件，结合工作经验对医保骗保问题进行分析，以期更好地解决骗保问题，保证医保基金平稳有序向前发展。本文以天津市H区医疗保险运行情况为例，综合利用管理经济学中信息不对称理论和博弈论等相关知识，以调查研究法、文献分析法和描述性研究法为主要研究方法，结合H区实际情况，在近年来查破的违规骗保案件中得到的经验基础上，从天津市社会医疗保险市场的发展、城职和城乡医疗保险的内容等方面分析了天津市医疗保险市场的特征；从医疗服务的提供方、需求方和医疗保险的管理机构等方面分析了天津市H区的骗保及其原因，并从医疗保险信息系统、医疗保险信誉监督机制和医疗保险市场的制度约束等方面提出了对策建议。
[Abstract]:As an important part of social insurance in Tianjin, social medical insurance in Tianjin has gone through more than ten years. With the continuous adjustment of policies, the medical treatment enjoyed by the insured people is increasing year by year, however,Social medical insurance fraud has been emerging, only from Tianjin City, each year the conservative estimate of the amount of insurance fraud is in the hundreds of millions.This harms the vital interests of most legally compliant medical institutions and insured people, and seriously affects the smooth operation and safety of health care funds.The author has been in charge of medical insurance for many years in H District of Tianjin City, and has been involved in investigating many cases of medical insurance fraud outside the district. In order to solve the problem of fraud insurance better, the author analyzes the problem of medical insurance fraud insurance in combination with his work experience.To ensure the smooth and orderly development of health insurance funds.Taking the operation of medical insurance in H district of Tianjin as an example, this paper makes comprehensive use of information asymmetry theory and game theory in management economics, and takes investigation and research method, literature analysis method and descriptive research method as the main research methods.In light of the actual situation in area H, and on the basis of the experience gained in the cases of illegal fraud and insurance found in recent years, from the development of the social medical insurance market in Tianjin,This paper analyzes the characteristics of Tianjin medical insurance market in terms of the contents of urban and rural medical insurance, the providers of medical services, the demand-side and the management agencies of medical insurance, and analyzes the reasons for the fraud and insurance in the H District of Tianjin.The countermeasures and suggestions are put forward from the aspects of medical insurance information system, medical insurance credit supervision mechanism and the system restriction of medical insurance market.
【学位授予单位】：河北工业大学
【学位级别】：硕士
【学位授予年份】：2014
【分类号】：F842.684;D924.3

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