Forgery of hospitalization and false opening of projects... The National Medical Insurance Administration reported 10 illegal cases of medical insurance fund fraud | medical insurance
On June 27th, the National Medical Insurance Administration reported 10 typical cases of illegal use of medical insurance funds, involving forged hospitalization, forged medical records, forged receipts, false opening of diagnosis and treatment items, false opening of medication orders, false storage, and impersonation of medical insurance cards.
1. Case of Insured Yuan Moumou Falsely Invoicing Medical Security Fund in Danzhai County, Qiandongnan Prefecture, Guizhou Province
In June 2022, when the Medical Insurance Center of Danzhai County, Qiandongnan Prefecture, Guizhou Province reviewed the sporadic reimbursement data, it was found that Yuan Moumou's monthly reimbursement of outpatient chronic and special illness expenses and invoices were abnormal, and there were abnormalities by comparing the bill style, watermark and bill seal. According to the on-the-spot investigation by Danzhai County Medical Insurance Bureau, Yuan Moumou made false bills to defraud the medical insurance fund, involving an amount of 100459.33 yuan. On August 30, 2022, the county health insurance bureau transferred the clue to the judicial authority. After verification, it is true that Yuan Moumou falsely issued bills to defraud the medical insurance fund, involving the medical insurance fund 100459.33 yuan. On May 16, 2023, in accordance with the the People's Republic of China Criminal Law, the the People's Republic of China Criminal Procedure Law, and the Answers to Several Questions on the Specific Application of Laws in Handling Fraud Criminal Cases, the Danzhai County People's Court made the following judgment: Yuan Moumou was guilty of fraud. Sentenced to three years and three months in prison and fined RMB 5,000. At present, the loss of medical insurance fund 100459.33 yuan has been fully recovered.
Lidu Hospital of Nanjing City, Jiangsu Province, 2. to defraud medical insurance fund case
In September 2021, the Nanjing Medical Insurance Bureau of Jiangsu Province, after big data screening analysis, on-site inspection and investigation, found that Nanjing Lidu Hospital was suspected of defrauding medical insurance funds by means of falsifying patient hospitalization and fictitious medical service items between April 2020 and August 2021. Subsequently, the Nanjing Medical Insurance Bureau promptly transferred the clue to the public security department. In July 2022, the Nanjing Medical Insurance Department recovered 5.297 million yuan of the overall fund involved in the case; in March 2023, the Nanjing Intermediate People's Court made the following judgments: 1. President Gu Moumou was guilty of fraud and sentenced to 12 years in prison. A fine of RMB 400,000; 2. The person in charge of finance Cheng Moumou was sentenced to three years in prison for fraud, suspended for four years, and fined RMB 100,000.
3. Baoshan District of Shanghai cracked the case of insured persons lending medical insurance cards to defraud medical insurance funds.
In May 2021, the Shanghai Baoshan District Medical Security Bureau found that the medical expenses, frequency of visits and medical trajectory of the insured person Lu Moumou and the medical insurance card were obviously abnormal during the abnormal audit of the insured person's outpatient and emergency treatment and medical expenses, and there was a case of suspected illegal use. Through further data analysis and examination and inquiry, it was verified that Lu Moumou's live-in nanny Xu Moumou and talked about the existence of the act of lending the medical insurance card to others. According to the "Shanghai Basic Medical Insurance Supervision and Administration Measures" and related regulations, the Baoshan District Medical Security Bureau recovered the full amount of 117000 yuan incurred by Xu Moumou and Tan Moumou in illegally lending medical insurance cards, and imposed 5000 yuan and 1000 yuan respectively. Administrative fines. At the same time, the Baoshan District Medical Security Bureau took the initiative to connect with the district public security branch to carry out execution connection, promptly transfer suspicious clues, and cooperate with the public security investigation. After careful investigation, the Baoshan District Public Security Bureau destroyed the fraud and insurance criminal gang in August 2021, and successfully arrested the fraud national medical insurance fund gang headed by Wang and Li, involving more than 100 million yuan. In February 2023, in accordance with the the People's Republic of China Criminal Law, the Shanghai Baoshan District People's Court ruled as follows: Wang was guilty of fraud and sentenced to 11 years and 6 months in prison, and a fine of 100,000 yuan; Li was guilty of fraud. Sentenced to ten years and six months in prison and fined one hundred thousand yuan. So far, all the illegal gains have been turned over.
4. case of Wang Moumou defrauding medical insurance fund in Jiuzhaigou County, Aba Prefecture, Sichuan Province
In 2021, the Medical Security Bureau of Jiuzhaigou County, Aba Prefecture, Sichuan Province investigated and verified Wang's hospitalization and outpatient medical expenses based on the doubtful data fed back by the audit department. It was found that Wang had participated in basic medical insurance in both places at the same time. After using the local insurance information for direct settlement, he went to Jiuzhaigou County for medical treatment to defraud the medical insurance fund through forged bills, which was suspected of fraud. Jiuzhaigou County Medical Insurance Bureau transferred the case materials and clue information to the public security organs for handling. After verification, since October 2017, Wang Moumou has forged 40 bills of the same time period and the same detailed amount after several online settlements at the place of medical treatment, and applied to the Jiuzhaigou County Medical Insurance Department for reimbursement of medical insurance treatment in other places, defrauding the medical insurance fund of 616219.54 yuan. On September 24, 2022, in accordance with the the People's Republic of China Criminal Law, the Jiuzhaigou County People's Court made a judgment in accordance with the law: Wang Moumou was guilty of fraud and sentenced to ten years and three months in prison and a fine of 50,000 yuan. At present, the public security organs have recovered 202608.00 yuan of medical insurance fund according to law and continue to recover the remaining amount of illegal income.
5. Jiangyin City, Jiangsu Province Fifth People's Hospital pharmacy staff Xu Mou defrauding medical insurance fund case
In October 2021, after a joint investigation by the Jiangyin Medical Insurance Bureau and the Public Security Bureau of Wuxi City, Jiangsu Province, it was found that Xu, a former pharmacy staff member of the Fifth People's Hospital of Jiangyin City, bought more than 600 kinds of drugs in Jiangyin Fifth People's Hospital, Jiangyin Zhutang Community Health Service Center and Maolong Village Clinic of Zhutang Town, Jiangyin City, resulting in a total loss of more than 1.82 million yuan. Subsequently, Wuxi medical insurance department recovered more than 1.82 million yuan of medical insurance fund involved in the case. In July 2022, the local people's court made the following judgment: Xu committed fraud and was sentenced to three years and three months' imprisonment and a fine of 50,000 yuan.
Case of defrauding medical insurance fund by Beixu Xiaoyang Hospital in Linying County of Henan Province in 6.
In July 2021, when the staff of the Suixian Medical Security Bureau of Shangqiu City, Henan Province reviewed the medical materials of patients in different places, they found that individual local residents were suspected of falsifying medical records in the hospitalization materials of Beixu Xiaoyang Hospital in Linying County, Luohe City. After a joint inspection of the hospital by the public security bureaus and medical security bureaus of the two places, it was found out that the hospital induced patients to be hospitalized by means of free accommodation and car pick-up, without any treatment during hospitalization, and the illegal act of falsifying patients' medical records to defraud the medical insurance fund, involving 65 insured persons in 11 prefectures and cities, 23 counties and districts in the province, and the amount involved was 1.1775 million yuan. On June 27, 2022, the Suixian People's Court sentenced the 11 people involved in the case to fixed-term imprisonment ranging from 12 years to one year, and fines ranging from 50,000 to 5,000 yuan.
7. Case of Illegal Use of Medical Insurance Fund in Tonglin Hospital of Jixi City, Heilongjiang Province
In 2021, when investigating a case of violation of law and discipline, the Commission for Discipline Inspection of Jixi City, Heilongjiang Province, found that Jixi Tonglin Hospital was suspected of fraudulently obtaining medical insurance funds. The Jixi Municipal Commission for Discipline Inspection and the Jixi Public Security Bureau established the Jixi Tonglin Hospital Fraud and Insurance Case Task Force to investigate the case. In the process of investigation, the health department organized experts to review the retrieved medical records, and the medical insurance department organized personnel to verify the reimbursement details that occurred during the period of time, and at the same time checked the data of the hospital's suspected drug purchase, sale and storage. Finally, it was determined that Jixi Tonglin Hospital had serious fraudulent and illegal acts such as induced hospitalization, fictitious medical services, fabricated false medical records, and false hospitalization. According to the "Jixi City Medical Insurance Designated Medical Institution Service Agreement", Jixi City Medical Insurance Bureau granted the hospital the qualification of designated medical institutions for medical insurance; Jixi City Public Security Bureau confiscated 17852364.38 yuan of medical insurance fund illegally used in accordance with the law, returned it to the fund account, and transferred it to the procuratorial organ for prosecution. On April 2, 2022, the People's Court of Jiguan District, Jixi City ruled as follows: Cai Moumou was guilty of fraud and sentenced to three years in prison and five years of probation; at the same time, Cai Moumou was prohibited from engaging in private hospital management activities during the probation period.
Case of defrauding medical insurance fund by Tianjin Hebei Minsheng Outpatient Department in Hebei District of Tianjin in 8.
On April 25, 2019, after on-the-spot inspection, interview and retrieval of information by the local medical insurance department, it was found that there was an illegal act of returning cash from the medical insurance card in the outpatient department, involving the payment amount of 1361030.09 yuan from the basic medical insurance fund. On May 27, 2019, Tianjin Medical Security Bureau transferred the case to Hebei Branch of Tianjin Public Security Bureau to investigate its criminal responsibility according to law. On June 10, 2021, the first-instance judgment of the People's Court of Hebei District, Tianjin was as follows: 1. The legal representative Yin Moumou committed the crime of fraud and was sentenced to nine years in prison and a fine of three hundred thousand yuan; 2. The administrator and the person in charge of medical insurance For the crime of fraud, he was sentenced to five years in prison, two years and six months in prison, and fined 10,000 yuan and 50,000 yuan. During the trial, Yin Moumou voluntarily returned the involved fund 1361030.09 yuan. The above-mentioned defendant appealed against the judgment of the first instance, and on October 11, 2021, the second intermediate people's Court of Tianjin made a ruling to uphold the original judgment.
Case of 9. Shangsi Chaoyang Hospital in Fangchenggang City, Guangxi Zhuang Autonomous Region, falsely reported the use of drugs to defraud the medical insurance fund
In July 2019, the Medical Security Bureau of Fangchenggang City, Guangxi Zhuang Autonomous Region found during on-site supervision and inspection that Shangsi Chaoyang Hospital was suspected of falsely reporting the use of drugs. On August 6, 2019, the Medical Insurance Bureau promptly transferred the investigation of the case to Fangchenggang City Public Security Bureau for investigation. After investigation, during the period from January 22 to July 31, 2019, Shangsi Chaoyang Hospital overdeclared the drug price through the medical insurance system, totaling 932825.13 yuan, of which 483462.85 yuan was overdeclared from January to May 2019, and the remaining 449362.28 yuan was overdeclared due to the medical insurance department's discovery that the payment was not made. According to the "2019 Basic Medical Insurance Work Injury Insurance and Maternity Insurance Service Agreement for Designated Medical Institutions in Fangchenggang City", the local medical insurance department's handling results are as follows: terminate the designated service agreement of Shangsi Chaoyang Hospital and recover the illegal amount of 806740.44 yuan. On March 30, 2021, in accordance with the relevant provisions of the the People's Republic of China Criminal Law and the the People's Republic of China Criminal Procedure Law, the Shangsi County People's Court ruled as follows based on the facts, nature, circumstances and the degree of harm to society of the defendant's crime: Ling Moumou, Wu Moumou, Wei Moumou, Zhou Moumou, Li Moumou, Liu Moumou and others constituted the crime of fraud, and were sentenced to fixed-term imprisonment ranging from ten to three years according to light, fines ranging from $80,000 to $20,000 were also imposed. The stolen money 463462.85 yuan withdrawn by Ling Moumou and 20000.00 yuan withdrawn by Zhou Moumou shall be returned to the medical insurance fund account by the people's Procuratorate of Shangsi County, the temporary detention authority.
10、 The case of Daqing Road Tongxing Street Community Health Service Station in Pingcheng District, Datong City, Shanxi Province defrauding medical insurance funds
In April 2019, the Medical Security Bureau of Datong City, Shanxi Province received a report clue, reporting that the community health service station on Daqing Road and Tongxing Street in Pingcheng District of Datong City had engaged in insurance fraud. After verification, it was found that the health service station was suspected of engaging in fraudulent insurance practices such as fabricating medical service projects, forging materials, and uploading false medication data. According to the Social Insurance Law of the People's Republic of China and the Service Agreement for Basic Medical Insurance Designated Medical Institutions in Datong City, the local medical insurance department's handling results are as follows: 1. Terminate the medical insurance service agreement and refuse to accept applications from designated medical insurance units within three years; 2. Transfer the case materials and clue information suspected of fraudulently obtaining medical insurance funds, such as forging hospitalization medical records, to the local public security organs for investigation and processing in accordance with the law. After the case was transferred to the public security department, the person involved in the case, Zhu, was criminally detained on suspicion of fraud. After further investigation by the public security department, relevant evidence was fixed and the above illegal facts were determined. A total of 3439893.13 yuan was suspected of defrauding medical insurance funds. On October 12, 2020, the People's Court of Pingcheng District, Datong City ruled as follows: Zhu committed the crime of fraud and was sentenced to 15 years in prison and fined RMB 100000. At present, the medical insurance fund loss of 3439893.13 yuan has been fully recovered.
The National Medical Insurance Administration stated that the above-mentioned illegal activities have caused losses to the medical insurance fund, disrupted the order of medical security management, damaged the vital interests of the majority of insured persons, had a negative social impact, and the relevant personnel have been severely punished by law. The medical insurance department will crack down severely on illegal activities such as fraud and insurance fraud, enhance the supervision of medical insurance funds, improve the efficiency of medical insurance fund utilization, maintain the safety of medical insurance funds, and safeguard the "medical expenses" and "life-saving funds" of insured persons.
