Research on Risk Management and Control of Medical Insurance Funds

DOI: https://doi.org/10.62517/jmsd.202512602

Author(s)

Yamin Chen

Affiliation(s)

School of Humanities and Social Sciences, Nanjing University of Aeronautics and Astronautics, Nanjing, Jiangsu, China

Abstract

This paper focuses on the research of risk management and control in medical insurance funds. First, it examines the research background and significance, analyzing the importance of risk management in medical insurance funds and reviewing the current research status both domestically and internationally. Second, in the theoretical foundation section, it introduces basic concepts of risk management and constructs a theoretical framework for medical insurance fund risk management. Regarding internal control, it elaborates on the concepts and principles of internal control, explores its application in medical insurance fund risk management, analyzes existing issues, and proposes improvement measures. In terms of external supervision, it explains the concept and role of external supervision, analyzes the external supervision system for medical insurance fund risk management, and suggests improvements to regulatory systems and standardization of supervisory practices to evaluate their effectiveness. Regarding informatization, it discusses the significance of informatization for risk management, analyzes the current status of informatization construction, identifies existing challenges, and proposes measures to enhance informatization in medical insurance fund risk management. Finally, through case analysis, it presents practical examples of risk management and offers targeted countermeasures and recommendations. In conclusion, this paper focuses on the risk management and control of medical insurance fund, and studies the internal control, external supervision, information construction, etc. in order to provide theoretical support and practical guidance for the risk management of medical insurance fund.

Keywords

Medical Insurance Fund; Risk Management; Internal Control; External Supervision; Information Construction

References

[1] Dong Dandan, Sun Niuyun, Sun Dongyue, et al. Effective Use of Medical Insurance Funds: Risk Management, International Experience, and Policy Recommendations. China Health Policy Research, 2013,6(1):21-27. [2] Zhang Xianjing. Research on the Risks and Countermeasures of Medical Insurance Funds. China Health Resources, 2011,14(04):240-242. [3] Ma Liang, Feng Haihuan, Li Yuntian. A Study on the Supervision Model of Public Hospital Medical Insurance Funds. Health Economics Research, 2023,40(8):78-80. [4] Zhu Kun, Shi Wenkai, Zhang Luying, et al. Analysis of China's Medical Security System from the Perspective of High-Quality Development. Health Economics Research, 2023,40(12):1-6+10. [5] Wang Wei, Zhang Ting, Huang Jincheng. Research on Key Elements and Operational Mechanism Model Construction for Provincial-level Medical Insurance Coordination. Journal of Health Economics, 2024,41(5):41-44+47. [6] Zhao Zhendong, Wang Bo. Analysis of Risk Prevention and Control in Direct Settlement between Medical Insurance Funds and Pharmaceutical Enterprises. China Medical Insurance, 2024(4):41-48. [7] Gao Shanshan, Ma Yunxia, Wu Qunhong. Research on the Construction of Internal Control System for China's Medical Insurance Administration Institutions Based on Grounded Theory. China Health Service Management, 2024,41(4):394-398. [8] Zhang Yanhua. Risk Assessment and Accounting Control Strategies in Medical Insurance Fund Supervision and Management. Financial Tribune, 2024(4):115-117. [9] Liang Hongmei, Liu Yajuan, Yang Shaochun. Manifestations, Causes, and Regulatory Strategies of Fee Violations in Public Hospitals. Journal of Health Economics, 2023,40(12):53-55+59. [10] Li Zhaodong, Song Jiaji. Research on the Supervision System and Pathways of National Audit in Promoting the Modernization of Healthcare Governance. China Health Economics: 1-11. [11] Lin Mei. Enhancing People's Quality of Life Through Institutional Development. People's Forum, 2024(15):38-42. [12] Zhu Jiaying, Gao Qilong, Mo Chunxia, et al. Research on the Current Status of Provincial Pilot Projects for National Healthcare Service Pricing Reform: A Case Study of Zhejiang Province. Journal of Health Economics, 2024,41(8):27-31.