On March 1, the "Guiding Opinions on Several Issues Concerning the Handling of Criminal Cases of Medical Insurance Fraud" was released, which is divided into five parts and a total of 26 articles.
Further clarification
Conviction and punishment of the crime of medical insurance fraud, and application of law
Policy grasp and case-handling requirements
and related work systems and mechanisms
Today
Let's find out
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1. What does the medical security fund include?
The medical security fund includes the basic medical insurance (including maternity insurance) fund, the medical assistance fund, the subsidy for large medical expenses for employees, the medical subsidy for civil servants, and the serious illness insurance fund for residents.
2. What kind of behaviors are fraudulent insurance fraud?
(1) Fraud and insurance fraud by designated medical institutions
Where designated medical institutions (medical institutions, drug business units) carry out any of the following acts for the purpose of illegal possession, and defraud the medical security fund of expenditures, the personnel who organize, plan, or carry out the work are to be convicted and punished as the crime of fraud in accordance with the provisions of Article 266 of the Criminal Law;
(1) Inducing or assisting others to impersonate or falsely seek medical treatment or purchase drugs, provide false supporting materials, or collude with others to issue false expense bills;
(2) Forging, altering, concealing, altering, or destroying medical documents, medical certificates, accounting vouchers, electronic information, test reports and other relevant materials;
(3) Fictitious medical service items and fictitious medical service fees;
(4) Decomposition hospitalization and bed hanging;
(5) Duplicate charges, over-standard charges, and decomposition project charges;
(6) Exchange of drugs, medical consumables, diagnosis and treatment items and service facilities;
(7) The medical expenses that are not covered by the medical security fund will be included in the settlement of the medical security fund;
(8) Other acts of defrauding the expenditure of the medical security fund.
Note: State employees of designated medical institutions who take advantage of their positions to carry out the acts provided for in the first paragraph to defraud the medical security fund shall be convicted and punished as the crime of embezzlement in accordance with the provisions of articles 382 and 383 of the Criminal Law.
(2) Fraudulent insurance by the insured
Where the perpetrator commits any of the following acts for the purpose of illegal possession, defrauding the medical security fund of expenditures, it is to be convicted and punished as the crime of fraud in accordance with the provisions of Criminal Law article 266;
(1) Forging, altering, concealing, altering, or destroying medical documents, medical certificates, accounting vouchers, electronic information, test reports, and other relevant materials;
(2) Using other people's medical insurance certificates to seek medical treatment or purchase drugs in a false name;
(3) Fictitious medical service items and fictitious medical service fees;
(4) Duplicate enjoyment of medical security benefits;
(5) Taking advantage of the opportunity to enjoy medical security benefits to resell drugs, medical consumables, etc., and accept the return of cash, goods or other illegal benefits;
(6) Other acts of defrauding the expenditure of the medical security fund.
Caution:
(1) The personal account of the insured person shall pay for others the medical expenses incurred in the designated medical institutions and the expenses borne by the individual in the purchase of drugs, medical devices and medical consumables in the designated retail pharmacies in accordance with the relevant regulations, which do not belong to the fraudulent medical treatment and drug purchase as provided for in item (2) of the preceding paragraph.
(2) Where, for the purpose of fraudulently obtaining medical security funds, other people's medical security certificates (social security cards, etc.) are purchased and used, and at the same time constitute the crime of buying and selling identity documents, the crime of using false identity documents, or the crime of fraud, it is to be convicted and punished with the heavier punishment.
(3) Stealing other people's medical security certificates (social security cards, etc.) and stealing funds from personal medical insurance accounts shall be convicted and punished as the crime of theft in accordance with the provisions of Article 264 of the Criminal Law.
(3) Fraudulent insurance by medical security institutions
Where the staff of the administrative department for medical security and the handling agency take advantage of their position to defraud the medical security fund of expenditures, they shall be convicted and punished as the crime of embezzlement in accordance with the provisions of articles 382 and 383 of the Criminal Law.
(4) Illegally purchasing or selling drugs
Those who clearly know that they are illegally purchasing or selling drugs purchased by medical insurance fraud are to be convicted and punished as the crime of covering up or concealing criminal proceeds in accordance with the provisions of Criminal Law article 312 and relevant judicial interpretations;
In any of the following circumstances, it may be found that the actor has subjective knowledge, except where the actor can explain the lawful source of the drug or make a reasonable explanation:
(1) The price of the drug is significantly different from the market price;
(2) Those who have received criminal or administrative penalties for illegally purchasing or selling drugs purchased through medical insurance fraud;
(3) Illegally purchasing or selling basic medical insurance drugs;
(4) Long-term or multiple purchases and sales of basic medical insurance drugs to unspecified transaction partners;
(5) Using the Internet, mail and other non-contact channels to purchase and sell basic medical insurance drugs for many times;
(6) Other circumstances sufficient to determine the perpetrator's subjective knowledge.
Fund supervision and participation
Guarding the "life-saving money" of the masses
It is everyone's responsibility to maintain the safety of the medical insurance fund
In case of insurance fraud
Please call the complaint and report hotline:
Minamikawa Ward Medical Health Bureau
023-64566378
The maximum reward is 200,000 yuan
Source: Nanchuan release