Beijing News Express (reporter Wu Wei) On December 8, the National Medical Insurance Bureau and the Ministry of Public Security announced a notice jointly issued by them, requiring them to strengthen the connection between administrative law enforcement and criminal justice investigation and punishment of cases of defrauding medical insurance funds. The circular puts forward a number of measures to combat fraudulent medical insurance fraud, and clarifies the scope and procedures for investigating and handling cases of fraudulent medical insurance funds.
"Decompose hospitalization, hanging bed hospitalization", these actors will be transferred to the public security organs
The notice jointly issued by the National Medical Insurance Bureau and the Ministry of Public Security clarifies the scope of transfer for investigating and handling cases of fraudulent medical insurance funds. It stipulates that if the administrative departments for medical security at all levels, in the course of supervision and law enforcement of medical insurance funds, discover that citizens, legal persons and other organizations have the acts listed in the "Circumstances of Transferring Cases of FraudulentLy Obtaining Medical Insurance Funds", and are suspected of committing a crime, they shall transfer them to the public security organs at the same level in accordance with law.
For example, medical insurance agencies forge, alter, conceal, alter, or destroy medical documents, medical certificates, accounting vouchers, electronic information, and other relevant materials; designated medical institutions induce or assist others to seek false medical treatment, hospitalization, or drug purchases, provide false certification materials, and collude with others to falsely issue expense documents; the above situations will be strictly investigated and handled by the public security organs.
It is worth noting that the "Circumstances of the Transfer of Cases of Fraudulent Medical Insurance Funds" also clearly lists some situations implemented by designated medical hospitals for the purpose of defrauding medical security funds. Such as decomposition hospitalization, hanging bed hospitalization; excessive diagnosis and treatment, excessive examination, decomposition of prescriptions, excessive prescriptions, repeated prescriptions or provision of other unnecessary medical services; double charges, excessive standard charges, decomposition of project charges; serial exchange of drugs, medical consumables, diagnosis and treatment items and service facilities; to facilitate the insured personnel to take advantage of their opportunity to enjoy medical security treatment to resell pharmaceutical consumables, accept the return of cash, physical goods or obtain other illegal benefits Inclusion of medical expenses that are not covered by the Medical Security Fund in the settlement of the Medical Security Fund; provision of medical insurance settlement for non-designated medical institutions or medical institutions in the period of suspension of medical insurance agreements in violation of regulations; illegal profits from fraudulent medical insurance vouchers.
At the same time, it also lists the relevant circumstances in which the insured individual commits relevant acts for the purpose of defrauding the medical security fund, resulting in the loss of the medical security fund: it involves handing over his or her medical security certificate to others for use under false names; repeatedly enjoying medical security benefits; taking advantage of the opportunity to enjoy medical security treatment to resell drugs, accepting the return of cash, in kind or obtaining other illegal benefits.
In cases of fraud and insurance fraud, public security organs must not accept transfer cases on the grounds that "the materials are incomplete."
In terms of the procedures for investigating and handling the transfer procedures for cases of fraudulent medical insurance funds, the circular proposes that in cases where the medical security administrative department transfers cases of fraudulent medical insurance funds, no less than 2 administrative law enforcement personnel should be determined to form a special case team. Public security organs shall accept cases of fraudulently obtaining medical insurance funds transferred by administrative departments for medical security. Where public security organs find that the case materials transferred by the administrative department for medical security are incomplete, they shall notify the administrative department for medical security transferring the case to complete it within 3 days within 24 hours of accepting the case, but must not accept the transferred case on the grounds that the materials are incomplete. Where public security organs find that a case transferred by the administrative department for medical security does not fall within the jurisdiction of that organ, it shall transfer it to the organ with jurisdiction within 24 hours, and inform the administrative department for medical security transferring the case in writing.
Public security organs shall conduct a case filing review from the date of accepting the case, and in principle the period for filing and reviewing the case does not exceed 3 days, where suspected criminal leads need to be verified, the time limit for filing and reviewing the case does not exceed 7 days, and in major difficult and complicated cases, upon approval by the responsible person for the public security organ at the county level or above, the time limit for filing and reviewing the case may be extended to 30 days. Where public security organs find that there are criminal facts and criminal responsibility should be pursued, the case is filed in accordance with law.
At the same time, the circular also requires that the public security organs should intensify the investigation and handling of cases of fraudulently obtaining medical insurance funds, promptly recover the medical insurance funds used in violation of the law and return them to the special account of the medical insurance funds, persist in severely punishing those who are behind the scenes organization manipulators, backbone members, professional card collectors, and professional drug dealers, treat first-time offenders and occasional offenders who are not harmful to society and are not deeply involved, and leniently deal with medical personnel and patients who admit guilt and accept punishment according to law.
Public security organs should concentrate superior police forces on major and important cases transferred by the administrative departments for medical security, use a variety of investigative methods, and quickly investigate and solve them
The circular proposes to establish a system of joint meetings and briefings. Medical security administrative departments and public security organs at all levels should hold joint meetings on a regular basis to exchange information on the investigation and handling of cases of fraudulent medical insurance funds and the connection between administrative law enforcement and criminal justice; through the construction of real-time analysis, early warning and monitoring models, and other means, analyze the situation and tasks of defrauding medical insurance funds, coordinate and solve problems in work, study and propose measures to strengthen prevention and investigation, promptly discover clues to illegal crimes of fraudulent medical insurance funds, and organize verification according to their authority. Administrative departments for medical security at all levels and public security organs should strengthen information reporting, and through work briefings, information networks, and other forms, promptly report and exchange relevant information, and realize information sharing.
Administrative departments for medical security at all levels and public security organs should also establish standardized and effective case management systems, strengthen case tracking and supervision and summary reports, and periodically report to higher-level departments on cases of defrauding medical insurance funds. Improve mechanisms for units and individuals to record and apply information on illegal and criminal acts of medical insurance funds, promoting the establishment of social creditworthiness. Strengthen the analysis of typical cases of illegal crimes defrauding medical insurance funds, summarize and grasp the characteristics of case laws, strengthen professional training, and continuously improve case investigation and handling capabilities and law enforcement levels. The administrative departments for medical security and public security organs shall supervise and inspect the implementation of this Notice by the administrative departments for medical security at lower levels and the public security organs, periodically conduct spot checks on the investigation and handling of cases, and promptly correct problems and deficiencies in the work of transferring cases.
Public security organs should concentrate superior police forces on major and important cases transferred by the administrative departments for medical security, use a variety of investigative methods, and quickly investigate and solve them. In cases with complicated cases and relatively large social impact, it is necessary to organize special forces to investigate and handle them, make all-out efforts to crack the cases, and announce the results of the investigation and handling to the public at an appropriate time. It is necessary to strengthen case consultation, handle cases in strict accordance with the law, and strictly distinguish between crimes and non-crimes in accordance with legally prescribed duties, powers, and procedures; it is necessary to prevent the substitution of fines for sentences and to handle them in a downgraded manner, and also to prevent the expansion of the scope of the crackdown.
background
From January to October this year, the national special action to combat fraudulent medical insurance funds recovered about 13.1 billion yuan in medical insurance funds and administrative fines
Why did the State Medical Insurance Bureau and the Ministry of Public Security jointly issue the Notice on Strengthening the Linkage between the Investigation and Handling of Cases of Fraudulent Medical Insurance Funds? The relevant person in charge of the National Medical Insurance Bureau interpreted the background of the notice.
According to the person in charge, in recent years, the State Medical Insurance Bureau and the Ministry of Public Security have always taken the crackdown on the illegal and criminal acts of fraudulent medical insurance funds as the primary task to grasp, continuously strengthen coordination, jointly crack down on the illegal and criminal acts of defrauding medical insurance funds, and initially build a high-pressure situation of cracking down on medical insurance fraud and insurance fraud.
From January to October 2021, in the national special action to combat fraud and medical insurance funds, a total of about 640,000 designated medical institutions were inspected, about 270,000 were investigated and punished, and about 13.1 billion yuan of medical insurance funds and administrative fines were recovered. However, the situation of medical insurance fund supervision is still grim, and illegal cases of fraudulent medical insurance funds still occur from time to time, such as medical insurance fraud cases in Cheng'an County, Hebei Province, and Shan County, Shandong Province.
"These cases warn us that the task of cracking down on the illegal and criminal acts of defrauding medical insurance funds is still very arduous and needs to be grasped unremittingly." The person in charge said that in order to enhance the comprehensive supervision capacity of the medical insurance fund and deepen the long-term mechanism of departmental linkage, the State Medical Insurance Bureau and the Ministry of Public Security have summed up and refined experience and practices in a timely manner, adapted to the development of the new situation of medical insurance fund supervision, deepened the cooperation between the medical insurance department and the public security department in terms of consultation mechanism, clue notification, information sharing, publicity and education, reward and punishment mechanism, etc., accelerated the construction of an operating mechanism that organically links administrative punishment of medical insurance funds and criminal justice, complements each other's advantages, and always maintains a high-pressure situation of cracking down on illegal and criminal acts of fraudulent medical insurance funds Promote the supervision of medical insurance funds in depth.
In the next step, the National Medical Insurance Bureau will work with the Ministry of Public Security to supervise the implementation of the requirements of the "Circular", effectively enhance the strong joint force of the administrative and judicial linkage to crack down on fraudulent medical insurance funds, more effectively investigate and curb illegal and criminal acts, deter lawbreakers and criminals, ensure the rational and effective use of medical insurance funds, and better protect the "medical treatment money" and "life-saving money" of the broad masses of the people.
Beijing News reporter Wu Wei
Trainee Editor Chen Jing Proofreader Yang Xuli
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