Research On The Problem Of Insurance Fraud And Prevention And Control Measures Of Designated Medical Institutions In County A, Sichuan Provinc

In recent years,medical insurance fraud has emerged in an endless stream,and the medical insurance fund has become the "meat of Tang Monk" in the eyes of some designated medical institutions and individuals.Under the background of relatively stable medical insurance collection policies and standards and the continuous decline of the birth rate,the income of the medical insurance fund will not increase significantly,while the expenditure of the medical insurance fund will continue to increase with the aging of the population,the expansion of the scope of payment and projects,and the improvement of the treatment level.If the phenomenon of medical insurance fraud cannot be effectively curbed,the medical insurance fund will face more severe operational risks and revenue and expenditure pressure.This study draws on the public product theory,information asymmetry theory and other relevant theories,and combines the case of insurance fraud in A County to conduct an in-depth analysis of the current situation of insurance fraud in A County,and summarizes the various manifestations,trends and harms to the economy and society of the current insurance fraud.Through in-depth analysis and research on the purchase behavior of drugs and consumables in public and private hospitals,the behavior of doctors’ salary system,the behavior of medical institutions making false invoices and idling drugs,and the behavior of inventory purchase and sales difference,the inspection and supervision methods of medical security institutions are discussed,and the correlation between the above factors is discussed,so as to further reveal the problems in the prevention and control of insurance fraud,that is,its root causes,On this basis,it is proposed to take the route of taking the optimization of system design as the basis,addressing both the root cause and the root cause,and comprehensive governance.The conclusions of this study include the following three aspects.First,the emergence of insurance fraud in designated medical institutions in A County is affected by complex and profound multiple factors,including the internal system of the medical industry,external supervision of government organizations,profit-seeking tendency of interest subjects,and the current situation of the convergence of laws and regulations.Second,insurance fraud has brought different degrees of negative effects on government finance,public goods and social climate.The existing prevention and control routes in A County are not sustainable,and the fundamental damage lies in optimizing system design and system reform.Third,ACounty should make comprehensive efforts to prevent insurance fraud from the aspects of medical industry system and mechanism,government supervision and assessment,social atmosphere construction,and medical industry constraints.The innovation of this study mainly includes two points: first,the innovation of research perspective.Because the medical insurance policy,insurance fraud means and prevention and treatment ability are greatly affected by local economic,social,cultural and technological factors,and the regional differences are very large,this study is based on the underdeveloped small county in the west,and the research perspective has certain innovation.The second is the innovation of the research content.At present,the existing research results on the prevention and control of fraudulent insurance mainly focus on the development of medical insurance supervision itself,while the research results on the combination of social governance and government governance are relatively few.From the internal perspective of the medical system and the external perspective of government supervision,this paper takes into account the social atmosphere and legal background of the formation of insurance fraud,and is more substantial in the research content.This study is only based on survey data and work experience,and conducts theoretical analysis on the causes of insurance fraud.The empirical test of the influencing factors has not yet been carried out.The scientificity of the relevant analysis needs to be discussed.We can do further research from the perspective of statistical analysis in the future.