基本医疗保险异地就医结算法律问题研究

发布时间：2018-03-19 08:51

本文选题：医疗保障权　切入点：基本医疗保险　出处：《西南政法大学》2015年硕士论文　论文类型：学位论文

【摘要】：随着我国经济发展水平和老百姓生活质量的不断提高完善,如何过上身心健康、体面尊严的生活已经成为政府和老百姓关注的头等大事。在实践层面,我国各级卫生部门、民政部门等为此做出了一系列努力。从1952年以公费医疗保障制度和劳保医疗制度为主体的城镇医疗保障制度建立之时起,到之后我国城镇职工医疗保险、新型农村合作医疗保险(以下简称“新农合”)和城镇居民基本医疗保险相继建立,我国目前实现了基本医疗保险全覆盖。在法制建设层面,我国有关医疗保险的法律制度不断完善,公民的“医疗保障权”和“人权”相继写入了《宪法》,《工伤保险条例》、《社会保险法》等陆续出台。目前,以《宪法》、《社会保险法》等法律为基础,我国已经初步建立起以城镇职工保险、城乡居民保险和“新农合”为主体的基本医疗保险制度体系。问题是,随着社会经济的发展进步,我国人口流动性日渐增强,基本医疗保险参保人员异地就医的现象日趋普遍,但我国并没有建立起基本医疗保险的统一制度。1998年,国务院颁布《关于建立城镇职工基本医疗保险制度的决定》(国发[1998]44号),确立了城镇职工基本医疗保险实行市级统筹的制度。在这一政策的引导下,此后的城镇居民医疗保险与“新农合”均沿用了市级统筹的制度设计。由此产生的一个不可忽视的法律问题是:由基本医疗保险统筹层次低造成的医保政策“碎片化”,使得参保人员在异地就医时无法享受到相对公平和高效的就医待遇。异地就医结算过程中的公平与效率问题凸显。除引言和结语外,论文共分为五个部分。第一部分是“基本医疗保险异地就医结算一般分析”。结合基本医疗保险制度,分析在此制度之下异地就医的成因和异地就医结算的现象。异地就医是由各地医疗卫生资源分布不平衡、参保人员就医需求与医疗资源分布不均之间的矛盾以及人口流动等诸多原因共同造成的。异地就医结算是基本医疗保险参保人员在参保地区之外就医后患者与诊疗医院、诊疗医院与社保经办机构之间进行的结算。目前,我国患者异地就医的规模增长迅速,相应地,异地就医保险结算的规模随之扩大,相关主体对异地就医保险结算的要求更加复杂和多样化起来。第二部分是“我国基本医疗保险异地就医结算的主要法律问题”。我国基本医疗保险制度具有“碎片化”的特点,即在不同的统筹地区,基本医疗保险的保障水平、保障实施的条件和程序等存在诸多差异,而异地就医结算过程中的法律问题值得深入分析。第一,参保人员异地就医面临突出的不公平问题。一方面,参保人员异地就医报销待遇差异过大,呈现出不同统筹地区参保人员在使用同等水平医疗资源情况下报销水平不同的特点。另一方面,由于异地结算真实性的监管难度较大,医保监管部门实行一套较为繁琐但对保险欺诈的监管效果欠佳的报销程序,导致不应该被报销的费用得到报销,参保人员应当合理报销的费用难以报销,这对守法参保人员有显著的不公平性。第二,异地就医的实时结算机制尚未完全建立,大多数统筹地区的异地结算程序繁琐,因为医疗保险结算体制不合理,参保人员在异地就医过程中实际上承受了许多不必要的负担。第三部分是“基本医疗保险异地就医结算法律问题的成因”。基本医疗保险异地就医结算中法律问题的成因可以归结为两个方面:第一,基本医疗保险的统筹层次较低。一方面,我国最早建立的城镇职工基本医疗保险统筹层次低,其后的城乡居民保险与“新农合”也延续了这一制度设计,基本医疗保险的统筹层次设计具有历史特点,在历次改革中还未取得突破性进展;另一方面,我国地区之间的经济发展水平差异较大,但我国在分税制财政管理体制基础上的财政转移支付制度未能有效均衡医疗资源配置,我国基本医疗保险政策“碎片化”的特点仍然十分明显。第二,基本医疗保险异地就医结算的管理与监督制度不完善。主要表现为:实时结算机制欠缺,异地就医结算保险欺诈的监管主体混乱,异地就医结算保险欺诈司法监督打击力度不够。第四部分是“欧盟跨国就医结算制度之考察”。考察欧盟跨国就医管理的解决方案,可以发现,欧盟跨国就医管理建立在协调性医疗保险政策之上,其协调性政策对于欧盟成员国公民跨国就医的公平与高效均有所保障。一方面,协调性医疗保险政策以欧盟成员国公民应该被公平平等地对待为原则;另一方面,标准化的管理、统一的跨国就医申请表格、真正意义上的“一卡通”使得其公民的跨国就医结算极为高效。第五部分是“破解我国基本医疗保险异地就医结算法律问题的路径”。笔者认为,通过医疗资源的均等化安排、提高基本医疗保险统筹层次、完善基本医疗保险异地就医结算管理与监督制度,有助于解决我国基本医疗保险异地就医结算过程中出现的法律问题。第一,通过医疗资源的均等化安排,尤其是对各地医院的诊疗设施、医护人员等医疗资源的均衡配置,可以从根本上引导参保人员合理就医,减少异地就医结算的规模和资源消耗。第二,实行省级统筹,建立区域性异地就医结算协调机制。通过财政转移支付的手段,统一省内基本医疗保险政策。通过签订异地就医结算协议的方式,实现经济发展水平趋同区域基本医疗保险政策的互认互惠。第三,完善基本医疗保险异地就医结算管理与监督制度,包括建立实时结算平台、厘清监管主体职责、加大对异地就医结算过程中不法行为的惩治力度。
[Abstract]:Along with the economic development level of our country and people constantly improve the quality of life improved, how to live a decent life of dignity and mental health, has become a top priority for the government and the people's attention. In practice, health departments at all levels in our country, the Civil Affairs Department, made a series of efforts. From 1952 to the establishment of public medical security system and medical insurance system as the main body of the urban medical insurance system to date, China's medical insurance for urban workers, the new rural cooperative medical insurance (hereinafter referred to as the "new") and basic medical insurance for urban residents have been established, China's current implementation of the basic medical insurance coverage. In the legal construction of our country level. The medical insurance legal system and constantly improve the citizens' right to health care "and" human rights "has been written into the constitution of < >, < >" byelaw of inductrial injury insurance, social insurance law etc. Have been introduced. At present, the < < > constitution, social insurance law > law, China has initially established by insurance for urban workers, urban and rural residents and the new rural cooperative insurance as the main body of the basic medical insurance system. The problem is that, with the progress of social economy, China's floating population increasing the basic medical insurance, the insured places for the increasingly common phenomenon, but our country has not set up a unified system of basic medical insurance for.1998 years, the State Council promulgated the "decision on the establishment of" basic medical insurance system for urban employees (Guofa [1998]44), established the basic medical insurance for urban workers, the implementation of municipal co-ordination system. Under the guidance of this policy, urban residents medical insurance and NRCMS after all follow the design of the system of municipal co-ordination. One can not ignore the legal problems caused by the basic is: Due to low overall level of the medical insurance policy of "fragmentation", the insured can not enjoy a relatively fair and efficient medical treatment in remote medical treatment. Remote medical problems of equity and efficiency in the settlement process highlights. Except the introduction and conclusion, the thesis is divided into five parts. The first part is "the basic medical the insurance of remote medical billing and general analysis. Combined with the basic medical insurance system, analysis of this system under the different medical causes and remote medical billing. The phenomenon is around by the remote medical health resources distribution imbalance, caused by the common insured medical needs and uneven distribution of medical resources between the various reasons and contradictions of population flow. Remote medical billing is the basic medical insurance insured in the insurance area outside the medical diagnosis and treatment of patients after hospital treatment, the hospital and the social security agencies Between the settlement. At present, Chinese patients with different medical scale is growing rapidly, accordingly, remote medical insurance settlement scale expanding, subjects of remote medical insurance settlement requires more complex and diverse. The second part is the main legal problems of China's basic medical insurance settlement remote medical basic. The medical insurance system in China has the characteristic of "fragmentation", namely in different regions, the level of protection of basic medical insurance, there are many differences between the guarantee conditions and procedures, and remote medical billing and legal issues in the process of further analysis. First, the insured medical unfair problems highlighted on the one hand, the insured medical reimbursement for the treatment difference is too large, showing the different areas in the use of the insured to the same level of medical resources under the reimbursement level The same features. On the other hand, because of the authenticity of the remote settlement supervision difficult, health supervision departments to implement a more complicated but not on insurance fraud supervision effect reimbursement procedures, resulting in the cost of reimbursement should not be reimbursed, the insured shall be reasonable reimbursement costs difficult to reimbursement, which is not fair obviously the law-abiding insured. Second, real-time settlement remote medical system has not been fully established, most regional co-ordination of remote settlement procedures cumbersome, because the medical insurance settlement system is unreasonable, the insured in remote medical process actually bear a lot of unnecessary burden. The third part is the "causes" of the basic medical insurance for remote medical law the problem can be settled. The causes of the basic medical insurance settlement remote medical legal problems in boils down to two aspects: first, the basic medical insurance plan Low level. On the one hand, the level of basic medical insurance for urban workers in China's first low, followed by urban and rural residents and the new rural cooperative insurance is a continuation of the design of the system, has the historical characteristics of the overall level of the design of the basic medical insurance, has not made a breakthrough in the previous reform; on the other hand and the difference of economic development level among the regions of our country is large, but in our country, the finance management system on the basis of the fiscal transfer payment system has failed to effectively balance the allocation of medical resources, the characteristics of the basic medical insurance policy in China "fragmentation" is still very obvious. Second, basic medical insurance management and supervision system of remote medical billing not perfect. The main performance is: the lack of real-time settlement mechanism, remote medical billing and insurance fraud supervision subject confusion, remote medical billing and insurance fraud crackdown without judicial supervision Enough. The fourth part is the "study" the EU transnational medical billing system. The influences of the EU transnational medical management solutions can be found, the transnational medical management based on the coordination of health insurance policies, ensure the coordination of policies for EU citizens multinational medical fair and efficient there. On the one hand, policy coordination medical insurance to EU citizens should be fair and equal treatment principle; on the other hand, standardized management, unified multinational medical application form, the true meaning of the "one card" makes its citizens transnational medical settlement is extremely efficient. The fifth part is the "path" to break the basic medical insurance in other places in China the medical legal settlement. The author believes that the equalization of the arrangement of medical resources, improve the level of basic medical insurance, improve the basic medical insurance remote medical knot Management and supervision system, law helps to solve the problem of China's basic medical insurance remote medical billing appeared in the process. First, the equalization arrangement of medical resources, especially for local hospital treatment facilities, medical personnel balanced allocation of medical resources, can guide the insured fundamentally reasonable medical treatment, reduce the size of remote medical billing and resource consumption. In second, the implementation of the provincial level, the establishment of a regional coordination mechanism for remote medical billing. By means of financial transfer payment, the basic medical insurance policy unified province. Through signing remote medical billing protocol, the realization of the basic medical insurance policy of the convergence of regional economic development level. Third mutual recognition improve the basic medical insurance, medical system and the supervision and management of settlement, including the establishment of real-time settlement platform, to clarify the regulatory responsibilities of the main, and of other The punishment of unlawful acts in the course of medical settlement.

【学位授予单位】：西南政法大学
【学位级别】：硕士
【学位授予年份】：2015
【分类号】：D922.182.3

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