摘要
社会医疗保险市场固有的信息不对称性,导致社会医疗保险欺诈案件时有发生。常见的欺诈形式主要表现为冒名顶替、病因作假以及各种报销资料作假等。中国的社会医疗保险制度起步较晚,在付费制度、管理模式、价格补偿模式、保险监管等方面存在许多亟待解决的问题。为减少社会医疗保险欺诈现象的发生,一方面可通过分析疑似索赔数据来识别可疑欺诈,另一方面可通过借鉴国外反欺诈的成功经验,从改革当前的医疗保险制度、建立奖惩机制、加强部门监管等方面入手采取有针对性的反欺诈措施。
The information asymmetry of social health insurance market leads to social health insurance frauds. Various fake reimbursement materials are the main form of frauds. Having a late start, social health insurance system in China is faced with many problems to be solved in payment system, management, price compensation mode, insurance regulation and other aspects. In order to reduce social health insurance frauds, the previous fraud claims data can be used to identify frauds. Furthermore, some specific anti-fraud measures should be taken, such as reforming the current health insurance system, establishing incentive mechanisms, and strengthening the sector regulation.
出处
《东方论坛（青岛大学学报）》
2013年第6期15-19,共5页
Eastern Forum（JOURNAL OF QINGDAO UNIVERSITY）
基金
国家自然科学基金面上项目(71273148)
山东省自然科学基金项目(ZR2010GM003)阶段性成果
关键词
社会医疗保险
欺诈行为
信息不对称
social health insurance
fraudulent conduct
asymmetry of information
