The "Notice on Strengthening the Investigation and Prosecution of Execution Connections in the Case of Fraudulently Obtaining Medical Insurance Funds" has taken the first step in execution cooperation in the field of supervision of my country's medical insurance funds and established the highest standard of execution connection.
In the past three and a half years, the National Medical Insurance Bureau's high-pressure crackdown on fraudulent insurance has recovered more than 50 billion yuan of medical insurance funds for the majority of insured persons. However, the regulatory situation of medical insurance funds is still severe, shocking the country with large amounts of fraud. Guarantee cases happen from time to time.
Recently, the National Medical Insurance Bureau and the Ministry of Public Security jointly issued the "Notice on Strengthening the Investigation and Punishment of Cases of Defrauding Medical Insurance Funds" (hereinafter referred to as the "Notice").
The "Notice" proposes that medical security administrative departments and public security organs at all levels implement the criminal justice policy of both leniency and strictness, and effectively strengthen the effective connection between the administrative law enforcement of the medical insurance fund supervision and criminal justice, so as to ensure that all dues are removed, all dues are collected, and administrative Penalties replace criminal accountability.
Lou Yu, a professor at the School of Civil, Commercial and Economic Law of China University of Political Science and Law and director of the Institute of Social Law, told China Business News that although the Criminal Law of the People’s Republic of China and its judicial interpretations have clearly stipulated the types of defrauding social security funds and the corresponding criminal offences. Responsibility, but the reality is that the medical insurance administrative agency believes that it is suspected of fraud and requires evidence collection and transfer, but it does not have the corresponding law enforcement powers and can only be transferred to the public security. The public security does not accept it for various reasons, and the connection between the two parties is not smooth. After all, the coordination mechanism of medical insurance supervision has not worked well in our country.
The two departments issued the "Notice" aimed at changing this situation.
Lou Yu said that the "Notice" has taken the first step in execution cooperation in the field of supervision of my country's medical insurance funds and established the highest standard for the connection of executions.
Recovery of 50.6 billion yuan in medical insurance funds in three and a half years
On the 8th, at the media briefing on “Strengthening Execution Linkage and Fighting against Fraud and Insurance” held by the National Medical Insurance Administration, Jiang Chengjia, Director of the Fund Supervision Department of the National Medical Insurance Administration, introduced that since the establishment of the National Medical Insurance Administration, there will be a total of from 2018 to October 2021. Approximately 2.34 million designated medical institutions were inspected, about 1 million were processed, and a total of 50.6 billion yuan in medical insurance funds were recovered.
The medical security fund is the people's "medical care money" and "life-saving money". The safety of its use involves the vital interests of the general public and is related to the healthy and sustainable development of the medical security system.
There are many users of medical security funds, long chains, many risk points, and difficult supervision. The supervision situation is relatively severe.
Some insured units, medical institutions, designated pharmacies and even patients regard the medical insurance fund as "tang monk meat" and resort to various means to defraud insurance.
In the case notified by the National Medical Insurance Administration on the 8th, there were cases in which insured persons from other places were collected to the company to participate in the insurance for illegal profit, and there were fraudulent behaviors in which retail pharmacies for special diseases used false prescriptions and false credit cards to sell medicines; there were some hemodialysis and organs. Transplant anti-rejection and other special disease personnel, sell medical insurance drugs to criminals who illegally trade drugs; some people are suspected of using the special disease certificates of the death special disease personnel to defraud medical insurance funds, and so on.
In recent years, it is not uncommon for insured persons to defraud large medical insurance funds.
In the case of Luo Mougui’s medical insurance fraud in other places in Shaoguan City, Guangdong Province, the insured Luo Mougui submitted 11 copies of the General Hospital of the People’s Liberation Army, the No. 302 Hospital of the People’s Liberation Army, and Peking University from 2015 to 2018. The hospitalization reimbursement materials of the three medical institutions including Shougang Hospital were reimbursed to the Shaoguan Social Security Agency (the last hospitalization application materials were not reimbursed). The declared total hospitalization expenses exceeded 810,000 yuan, and the reimbursed amount was 492,000 yuan.
According to investigations, Luo Mougui purchased and produced 11 false hospitalization reimbursement materials from the “ticket dealers” at the entrance of the hospital between 2015 and 2018, and applied for reimbursement of fraudulent medical insurance funds to the Shaoguan Social Security Office.
On August 10, 2020, the People’s Court of Wujiang District, Shaoguan City formally judged: Defendant Luo Mogui was guilty of fraud and sentenced to five years and 10 months’ imprisonment and fined RMB 70,000; he ordered the defendant Luo Mogui to Shaoguan The Municipal Medical Security Bureau refunded more than 450,000 yuan of illegal income.
In view of the risk of leaks in all aspects of the medical insurance fund, Lou Yu said that the medical insurance fund supervision case is highly professional, highly related to medical affairs management, and the types of illegal entities and illegal acts are complicated. A special departmental cooperation regulation has been formulated. It is very necessary. Under the background that my country has achieved universal medical insurance and the medical insurance industry is gradually moving towards standardization and rule of law, it is time for a regulatory document such as the "Notice" to be issued.
Criminal liability can be investigated for scam insurance amount of 3000~6000 yuan
The "Notice" mainly includes five parts, including the guiding ideology, scope of transfer, transfer procedures, working mechanism and requirements for strengthening the connection of execution of fraudulent medical insurance funds. It clarifies the scope of transfer. There are three main types of illegal and criminal subjects involved in the transfer of fraudulent medical insurance fund cases: Medical security agencies, designated medical institutions, and insured persons.
It also stipulates that the supervision of critical illness insurance, long-term care insurance, and medical assistance shall be implemented with reference to the medical insurance fund.
The "Notice" stipulates illegal and criminal acts that need to be transferred to the public security organs, including forgery, alteration, concealment, alteration, and destruction of medical documents, medical certificates, accounting vouchers, electronic information, etc., in violation of the "Regulations on the Supervision and Administration of the Use of Medical Security Funds" Relevant materials, or fictitious medical service items, etc., fraudulently obtain medical security funds and other illegal acts,
Lou Yu believes that the "Notice" establishes the highest standards for the connection of executions, adopts more stringent terms such as "exhaustible transfers" and "exhaustive collections due", and adopted "no administrative punishments to replace criminal liability investigations" to deal with administrative failures. As a clearly prohibited regulation, adhere to high standards and strict requirements.
Zhang Qing, a professor at the China University of Political Science and Law, said in his interpretation of the "Notice" that, currently, the minimum amount of fraudulent insurance determined by the provincial courts and prosecutors to constitute a criminal requirement for fraudulent insurance fraud of medical insurance funds is 3,000 to 6,000 yuan. In many provinces, if the value of medical insurance funds is more than 3,000 yuan (some provinces such as Chongqing, Henan, Hubei, etc., require more than 5,000 yuan, and Guangdong Province requires more than 6,000 yuan), the public security organs should file a case for criminal responsibility.
Lou Yu believes that in the future, it is possible to combine the joint meeting and the information notification system to attract experts in multiple fields such as medical technology, hospital management, law, and finance to jointly discuss and study the constituent elements of illegal and criminal behaviors of fraudulently obtaining medical insurance funds, and form a unified identification standard. It is also reported to the National Medical Security Administration and the Ministry of Public Security. These two departments regularly release typical cases and identification recommendations to gradually achieve simultaneous judgments in the same case, and finally achieve coordination and convergence between executions.
Jiang Chengjia said that the next step is to strengthen the supervision of medical insurance funds, focusing on key areas such as primary-level designated medical institutions, medical institutions set up in integrated medical care institutions, tampering with tumor patient genetic test results, hemodialysis fraudulent medical insurance fund behavior, medical insurance card illegal cash payment and other key areas , Improve the working mechanism for the connection of executions, and effectively maintain the safety of the medical insurance fund.
Author: Guo Jinhui