"同一盒药，现金买18元，刷医保卡却要25元"——这样的现象曾让不少患者既困惑又心寒。不久前，国 家医保局发布通知，要求进一步加强监测与处置医保定点零售药店药品"阴阳价格"问题，通过主动筛查 重点药品、深挖线索、调动社会监督，坚决遏制这一损害参保人利益的乱象。 所谓医保药品"阴阳价格"，是指同一药品在销售中对参保与非参保人员实行差别定价，参保患者买药反 而花钱更多。部分药店对此找的借口是因为医保结算周期长、垫付资金压力大，于是悄然把成本转嫁给 参保患者；还有药店以"会员优惠价"之名行差别定价之实，甚至在药品拆零销售、捆绑销售中玩起花 样。这些"套路"不仅蚕食医保基金，更会动摇公众对医保制度的信任。 "阴阳价格"反映出部分经营主体的投机心理。过去，由于信息化程度有限，问题发现难、取证难、处罚 轻。加上一些药品本身的渠道、定价等信息不透明，药店享有更大的主动权，使"阴阳价格"有了生存土 壤。如今国家医保局提出以大数据监测、智能比价系统、异常预警模型等手段强化实时监管，是从"被 动发现"向"主动感知"的转变。让违规行为在露头瞬间被锁定、被惩处，才能确保监管的威慑力。 治理"阴阳价格"还要疏堵并举。从药店角度看，医保 ...

Core Viewpoint - The recent cases of abnormal data in the healthcare system highlight the critical importance of data quality in ensuring the effective operation of medical insurance funds, which are essential for public health [1][5]. Group 1: Data Quality Issues - Numerous bizarre medical practices, such as a 73-year-old woman undergoing "painless egg retrieval" and male patients having hysteroscopy billing records, were identified as results of poor data quality management [1][5]. - The National Healthcare Security Administration (NHSA) has utilized a unified medical insurance information platform to identify and address these abnormal data cases, showcasing the empowering role of data in regulatory oversight [1][5]. Group 2: Implications of Data Errors - Errors in medical insurance data can trigger regulatory alarms and lead to on-site inspections, resulting in increased management costs for both regulatory bodies and medical institutions [5][7]. - The integrity of medical insurance funds, which are considered "lifesaving money" for the public, relies heavily on the quality of data management by designated medical institutions [5][7]. Group 3: Responsibilities and Recommendations - Designated medical institutions are urged to take primary responsibility for data quality, ensuring accurate reporting and ongoing verification to eliminate data risks at the source [7]. - Healthcare departments are encouraged to enhance their technical capabilities, implement intelligent monitoring and cross-verification mechanisms, and increase penalties for violations to ensure the proper functioning of medical insurance funds [7].

加强医保基金使用常态化监管，对保障基金安全运行、提高基金使用效率、规范医疗服务行为、减轻群众看病就医负担具有重要意义。随着医保改革的深 入和医保职能更加多样化，以基础规则、简单模型或人工抽查为主的传统监管模式难再适应新时代医保监管的工作要求，出现诸多问题： 一是审核效率 低、覆盖面窄、主观性较强； 二是属于管理领域控制职能的事后控制，作用有限，特别是医保支付方式改革后，新型违规行为涌现，如分解住院、高套 编码、费用转嫁等，传统监管手段难以应对这些专业化高、隐蔽性强的违规操作；三是单纯通过事后纠错规范医疗行为，难以适配医保和医疗协同发展和 治理的新格局。 信息化、数字化和智能化时代的到来，为以上问题的解决带来了契机。智能审核正是通过大数据和智能技术，引导医保监管深入临床路径、走进医生工作 站和覆盖电子病历或健康档案，有利解决或缓解了以上问题，实现对医疗费用高效、全程、客观、实时、动态监测。不仅有利于加强基金监管，更为医保 服务的提质增效和医保治理机制的建设完善提供了新型思路和有力工具，构建起覆盖"全领域、全流程、全要素"的医保智能监控体系，通过数智化转型重 塑监管范式，大力推进医保治理现代化发展。 一、政策引领 ...