【摘要】 [目的]分析医保欺诈的典型形式与监管措施现状，为实现医保基金监管改革提供建议。[方法]基于国家医保局公开的全国179例典型案例，采用内容分析法，梳理分析各类主体的骗保手段与监管措施等内容。[结果]179起案例中，骗保主体为定点医疗机构占52.6%、参保者占19.6%、定点零售药店占17.3%。不同主体间欺诈骗保行为存在差异，其中公立医院以医保服务不规范行为为主(64.3%)、民营医院以虚假医疗行为为主(61.5%)、参保者以虚假医疗报销行为为主(68.6%)。在基金监管措施方面，医疗机构的欺诈骗保行为主要通过医保局独立调查发现(30.9%),而零售药店主要根据举报线索调查发现(29.0%);机构类主体的惩戒依据主要为医保服务协议(39.7%),惩戒参保者主要依据刑法(60.0%);机构类骗保主体的惩戒方式主要为行政罚款(42.7%)、解除医保定点服务协议(38.9%);惩戒参保者的方式主要为有期徒刑并处罚金(74.3%)。[结论]当前医保欺诈典型形式包括民营医疗机构虚假医疗行为、公立医疗机构与零售药店医保服务不规范行为以及参保者虚假医疗报销行为骗保。监管措施以医保局独立监管为核心，辅以飞行检查与社会监督，机构类骗保主体与参保者的主要惩戒依据分别是医保服务协议与刑法。更多还原

【Abstract】 Objective This paper aims to analyze the typical forms of health care fraud and the current situation of regulatory measures, so as to provide suggestions for the reform of supervision of medical insurance funds. Methods Based on 179 typical cases disclosed by the National Healthcare Security Administration(NHSA), the content analysis method was adopted to sort out and analyze the types of insurance fraud of various subjects and regulatory measures. Results Among the 179 cases, the main bodies of insurance fraud were designated medical institutions(52.6%), participants(19.6%), and designated retail pharmacies(17.3%). There were differences in fraudulent behaviors in insurance perpetrated by different subjects. Public hospitals mainly had irregular behaviors in medical insurance services(64.3%). Private hospitals were dominated by false medical behaviors(61.5%). The participants mainly had false medical reimbursements(68.6%). In terms of supervision and management for funds, the fraudulent behaviors in insurance perpetrated by medical institutions were mainly found through the independent investigation of the NHSA(30.9%), and insurance fraud cases of retail pharmacies were mainly found through reports and investigation(29.0%). The main basis for punishing institutions was the medical insurance services agreement(39.7%), and the main basis for punishing participants was the Criminal Law(60.0%). The disciplinary methods for institutional insurance fraud cases were mainly administrative fines(42.7%) and the termination of the designated medical insurance services agreement(38.9%). The main disciplinary method for participants was fixed-term imprisonment with a fine(74.3%). Conclusions The typical forms of current health care fraud involve false medical practices of private medical institutions, non-standard medical insurance services of public medical institutions and retail pharmacies, and false medical reimbursements of insured persons. The regulatory measures take the independent supervision of NHSA as the core, supplemented by unannounced inspections and social supervision. The main basis for punishing institutional insurance fraud and participants is the medical insurance services agreement and the Criminal Law respectively.更多还原