Zhang Zixiao, Ding Shaoqun, Yang Zitao, Hu Huaxia
School of Public Administration, Southwestern University of Finance and Economics, Chengdu, Sichuan, China.
Aging and Social Security Research Center, Southwestern University of Finance and Economics, Chengdu, Sichuan, China.
PLoS One. 2025 Jan 6;20(1):e0313618. doi: 10.1371/journal.pone.0313618. eCollection 2025.
Fraud in medical insurance is a serious problem that threatens the safety and sustainability of medical insurance funds. The process of reducing or even eliminating the impact of fraud is related to maintaining the balance of payments for medical insurance funds and reforming the payment system based on total amount control. As a result of reviewing the policy background of medical insurance fraud in China, combined with the policy evaluation model in the area of public management, this paper develops a conceptual framework of 'Antecedents-Process-Outcomes' that emphasizes the fraud and governance of medical insurance funds. This paper uses grounded theory to look at 180 cases of medical insurance fraud and then uses the PMC index model to rate 18 policies. It then looks at the joint progressive analysis framework of medical insurance fraud and fraud supervision. In this paper, we analyze the policy similarities and differences of medical insurance fraud supervision in China from three perspectives: policy attributes, policy contents, and policy effects. The average PMC index of the 18 policies is 4.98, which is generally acceptable; however, there are some deficiencies in the policy field, policy supervision chain, policy orientation, and policy tools. Then, it puts forward suggestions for improving the four policy shortcomings in order to provide theoretical and practical enlightenment for the high-quality development of the medical security system and realize the new medical security in the process of Chinese-style modernization.
医疗保险欺诈是一个严重问题,威胁着医疗保险基金的安全与可持续性。减少甚至消除欺诈影响的过程关乎维持医疗保险基金收支平衡以及基于总额控制改革支付体系。通过审视我国医疗保险欺诈的政策背景,结合公共管理领域的政策评估模型,本文构建了一个强调医疗保险基金欺诈与治理的“前因—过程—结果”概念框架。本文运用扎根理论研究180起医疗保险欺诈案例,接着使用PMC指数模型对18项政策进行评分。随后考察医疗保险欺诈与欺诈监管的联合递进分析框架。本文从政策属性、政策内容和政策效果三个视角分析我国医疗保险欺诈监管政策的异同。18项政策的平均PMC指数为4.98,总体尚可;然而,在政策领域、政策监管链条、政策导向和政策工具方面存在一些不足。进而针对这四项政策短板提出改进建议,为医疗保障体系高质量发展提供理论与实践启示,在中国式现代化进程中实现新的医疗保障。