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医保体系涉及医、患、保三方,按照医保政策规定,国家用强制手段将百姓医保费用集中,交由医保中心管理,医保中心与医院签订协议,并支付医院预付的、医保应报销的部分,并对医院进行监督。患者到医院就诊后,到医保中心报销费用,三者之间应该保持一种顺畅、平衡的关系。然而总有某种力量将平衡打破,医保作为新医改的重要部分,其政策在实施过程中不可避免地出现了一些漏洞,违法违规行为也由此而生,其中以医院骗保最受人关注。一提起医院骗保,人们就很容易与“惟利是图”挂钩,谴责医生道德沦丧。不可否认的是,临床中的一些骗保行为是因医方的趋利性造成的,但除此之外,不完善的医保政策,也是众多医疗机构铤而走险的重要原因。医疗机构之所以出现与事实不符的处方、超量用药的行为,大多是因为医保政策中的一些条款与临床诊疗需求不符,从而使医生不惜损害自身声誉而犯险。因此,遏制医疗机构骗保需要医疗机构和医保部门共同努力。
The medical insurance system involves three aspects: medicine, suffering and insurance. According to the medical insurance policy, the state will use the compulsory means to concentrate the people’s medical insurance fees and pay them to the medical insurance center for management. The medical insurance center and the hospital sign an agreement and pay the hospital prepaid medical insurance part that should be reimbursed. And the hospital supervision. Patients to the hospital for treatment, to the Medicare center reimbursement costs, the three should maintain a smooth and balanced relationship. However, there is always some sort of power to break the balance. As an important part of new medical reform, medical insurance will inevitably have some loopholes in the implementation process, resulting in illegal and illegal behaviors. Among them, . Mentioning fraudulent insurance in the hospital will make it easy for people to link up with the “merits and demerits of figure” and condemn the doctor’s moral decline. It is undeniable that some of the fraudulent activities in the clinic are caused by the profitability of the medical profession. However, in addition, the imperfect medical insurance policy is also an important reason for many medical institutions to take the risk. The reason why medical institutions do not conform to the facts of prescriptions and overdose of medicines is because most of the provisions of the Medicare policy do not meet the needs of clinical diagnosis and treatment so that doctors can not hesitate to damage their own reputation. Therefore, to curb medical institutions to cheat insurance needs medical institutions and health insurance departments to work together.