本文選題：社會(huì)醫(yī)療保險(xiǎn)　切入點(diǎn)：騙保表現(xiàn)　出處：《河北工業(yè)大學(xué)》2014年碩士論文

【摘要】：作為天津市社會(huì)保險(xiǎn)的重要組成部分，天津市社會(huì)醫(yī)療保險(xiǎn)已走過(guò)十多個(gè)年頭，隨著政策的不斷調(diào)整，，參保群眾所享受到的醫(yī)療待遇在逐年提高，但是，社會(huì)醫(yī)療保險(xiǎn)中的騙保行為也一直不斷出現(xiàn)，僅從天津市來(lái)看，每年內(nèi)部測(cè)算騙保金額保守估計(jì)都在上億。這損害了大多數(shù)依法合規(guī)的醫(yī)療機(jī)構(gòu)和參保群眾的切身利益，嚴(yán)重影響了醫(yī)�；鸬钠椒�(wěn)運(yùn)轉(zhuǎn)和安全。本文作者在天津市H區(qū)負(fù)責(zé)醫(yī)療保險(xiǎn)工作多年，參與查辦區(qū)內(nèi)區(qū)外多起醫(yī)療騙保案件，結(jié)合工作經(jīng)驗(yàn)對(duì)醫(yī)保騙保問(wèn)題進(jìn)行分析，以期更好地解決騙保問(wèn)題，保證醫(yī)�；鹌椒�(wěn)有序向前發(fā)展。 本文以天津市H區(qū)醫(yī)療保險(xiǎn)運(yùn)行情況為例，綜合利用管理經(jīng)濟(jì)學(xué)中信息不對(duì)稱(chēng)理論和博弈論等相關(guān)知識(shí)，以調(diào)查研究法、文獻(xiàn)分析法和描述性研究法為主要研究方法，結(jié)合H區(qū)實(shí)際情況，在近年來(lái)查破的違規(guī)騙保案件中得到的經(jīng)驗(yàn)基礎(chǔ)上，從天津市社會(huì)醫(yī)療保險(xiǎn)市場(chǎng)的發(fā)展、城職和城鄉(xiāng)醫(yī)療保險(xiǎn)的內(nèi)容等方面分析了天津市醫(yī)療保險(xiǎn)市場(chǎng)的特征；從醫(yī)療服務(wù)的提供方、需求方和醫(yī)療保險(xiǎn)的管理機(jī)構(gòu)等方面分析了天津市H區(qū)的騙保及其原因，并從醫(yī)療保險(xiǎn)信息系統(tǒng)、醫(yī)療保險(xiǎn)信譽(yù)監(jiān)督機(jī)制和醫(yī)療保險(xiǎn)市場(chǎng)的制度約束等方面提出了對(duì)策建議。
[Abstract]:As an important part of social insurance in Tianjin, social medical insurance in Tianjin has gone through more than ten years. With the continuous adjustment of policies, the medical treatment enjoyed by the insured people is increasing year by year, however,Social medical insurance fraud has been emerging, only from Tianjin City, each year the conservative estimate of the amount of insurance fraud is in the hundreds of millions.This harms the vital interests of most legally compliant medical institutions and insured people, and seriously affects the smooth operation and safety of health care funds.The author has been in charge of medical insurance for many years in H District of Tianjin City, and has been involved in investigating many cases of medical insurance fraud outside the district. In order to solve the problem of fraud insurance better, the author analyzes the problem of medical insurance fraud insurance in combination with his work experience.To ensure the smooth and orderly development of health insurance funds.Taking the operation of medical insurance in H district of Tianjin as an example, this paper makes comprehensive use of information asymmetry theory and game theory in management economics, and takes investigation and research method, literature analysis method and descriptive research method as the main research methods.In light of the actual situation in area H, and on the basis of the experience gained in the cases of illegal fraud and insurance found in recent years, from the development of the social medical insurance market in Tianjin,This paper analyzes the characteristics of Tianjin medical insurance market in terms of the contents of urban and rural medical insurance, the providers of medical services, the demand-side and the management agencies of medical insurance, and analyzes the reasons for the fraud and insurance in the H District of Tianjin.The countermeasures and suggestions are put forward from the aspects of medical insurance information system, medical insurance credit supervision mechanism and the system restriction of medical insurance market.
【學(xué)位授予單位】：河北工業(yè)大學(xué)
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2014
【分類(lèi)號(hào)】：F842.684;D924.3

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