中国医疗保障基金监督管理发展报告（2023～2024）
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中文摘要
本书系统总结了2022年我国医保基金监管工作开展情况，分析当前遇到的问题与挑战，并对下一阶段医保基金监管事业发展形势和重点进行研判，提出相关对策建议。
2022年度我国医疗保障基金监管工作继续强力推进，进展成效显著。一是持续巩固基金监管高压态势。通过飞行检查、专项整治和日常监管相结合，打击欺诈骗保工作不断走向深入，全国各级医保部门共检查定点医药机构76.7万家，处理违法违规机构39.8万家。同时，规范举报奖励，以问题为导向，加强重点领域监管，使监管工作更加聚焦、精准。运用医保、公安联合督导挂牌和重大案件同步上案等机制，打击整治效能明显提高。加强宣传曝光，活用正反两方面典型，发挥正向激励、警示震慑作用。二是建立健全基金监管长效机制。医疗保障基金监管制度体系改革加快推进，基金监管法治体系加速构建，部门综合监管机制进一步强化，同时，以信息化赋能推动基金监管向数字化监管转型，持续提升监管质效。此外，地方基金监管队伍不断加强，探索形成了许多具有地方特色的基金监管新模式、新经验。
报告指出当前医保基金监管面临着新的历史机遇。在党中央、国务院的高度重视下，经过全国医保系统5年多的努力，政府监管和社会监督的良性互动，广大群众监督意识不断加强，维护基金安全氛围浓厚。全国统一的医保信息平台建成，为实施大数据战略奠定了基础；跨部门综合监管模式深入推进，实现了更大程度上的系统互联和数据互通；支付方式改革快速推进，激发供给端主动规范服务，控本增效。同时也面临着一些新挑战，如医保基金长期可持续运行压力增大、多层次法规体系建设不完善、监管队伍建设不健全、医保改革全面深化出现基金监管新内容、监管科技的广泛运用导致博弈升级等。
报告建议医保基金监管工作要坚持以人民健康为中心，推动监管重心前移，强化医保数据赋能，不断完善非现场监管与现场监管有机结合的监管格局，筑牢事前提醒、事中审核、事后监管的防线。同时，要着眼系统性布局，促进医保、医疗、医药协同发展和治理。要健全监督管理、协同监管、跨区域监管执法等机制，有效破解各类监管难题。通过部门协同联动，激励和约束并举，促进定点医药机构规范合理使用医保基金。
同时，建议定点医药机构顺应医疗医保高质量发展的总体要求，强化自我管理主体责任，建立健全医保服务、财务、信息安全等内部管理机制，不断提升精细化管理水平，履行行业自律公约，自觉接受医保监管和社会监督，共同维护医保基金安全和有效使用，实现医保与医院可持续发展。
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医院医保管理
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