芮晨 尹淼 郭栋伟 李艳霞

【摘 要】当前，我国经济进入新常态，在政治、经济、科技、文化、教育、卫生等方面发生了一系列社会变革，面临的社会问题十分复杂，迫切需要各类智库的研究和分析为政府提供理论、技术、方法、策略和政策建议。与此同时，面对即将到来的泛化智能新时代，智库建设也亟待加速向智慧化演进。论文提出，基于健康大数据、云计算、人工智能的医保费用欺诈监管策略可以实现医疗决策智库的智慧化，实现对医保费用欺诈行为的智能识别，针对政府机构和其他客户开展“预见性和预防性决策咨询”，对医疗卫生经济的发展有着重要的推动作用。

【Abstract】At present， China's economy has entered a new normal， and a series of social changes have taken place in politics， economy， science and technology， culture， education， health and other aspects. The social problems we faced are very complex. There is an urgent need for the research and analysis of various think tanks to provide the government with theoretical， technical， methodological， strategic and policy suggestions. At the same time， in the face of the coming new era of generalized intelligence， think tank construction also needs to accelerate the evolution to intelligence. The paper proposes that the supervision strategies of the fraud of medical insurance costs based on health big data， cloud computing and artificial intelligence can realize the intelligence of medical decision-making think tanks， realize the intelligent identification of the fraud behavior of medical insurance costs， and carry out "consultation on predictive and preventive decision-making" for government agencies and other customers， which plays an important role in promoting the development of medical and health economy.

【关键词】智库智慧化;医保费用欺诈;大数据;决策

【Keywords】intelligence of think tanks; fraud of medical insurance costs; big data; decision-making

【中图分类号】R197.1                                             【文獻标志码】A                                【文章编号】1673-1069（2019）12-0122-03

1 研究背景

随着中国经济发展进入新常态，政治、经济、科技、文化、教育、卫生等领域的变化显著，针对当前复杂的社会问题，迫切需要各类智库在研究和分析的基础上，为政府提供适用于解决我国现实问题的理论、技术、方法、策略和政策方面的建议。自从2009年新一轮医药卫生体制改革启动以来，我国社会医疗保险制度已逐步改进，并在解决公民疾病风险方面发挥了很好的作用[1]。但是，随着医保费用的不断提高和医保制度重要性的日渐凸显，医保费用欺诈等违规现象在全国范围内呈上升趋势，且涉及面广、不易发现。医疗保险费用监管不仅是国家有关部门和地方政府工作的重点，也是我国医疗决策智库的研究重点。……