Life saving money has become Tang Monk meat, and there are many cases of defrauding medical insurance fund

 Life saving money has become Tang Monk meat, and there are many cases of defrauding medical insurance fund

How can life saving money become Tang Monk meat?

Li Wanxiang, reporter of China Economic Daily

In life, if someone borrows your medical insurance card for the reasons of helping to buy medicine or failing to meet the reimbursement threshold, you should be careful! Because you rent or lend your own medical insurance card, it may be taken by criminals to defraud the medical insurance fund. Must not for petty gain, rent out their own medical insurance card.

In recent years, some units and individuals try their best to exploit the loopholes in the rules, engage in commercial bribery, collude up and down, and wantonly defraud the national health insurance fund. From the many cases of defrauding the medical insurance fund, it is easy to see that each person is involved in several million yuan. How to protect our medical insurance card? What loopholes still exist in the medical insurance system that need to be improved? Please see the reporters interview.

Many cases of defrauding medical insurance fund

A few days ago, the reporter learned from the second intermediate peoples Court of Beijing that from August 2019 to August 2020, the court and its jurisdiction tried 35 cases of fraud of medical insurance fund, with 47 defendants, with a crime amount of more than 46 million yuan and a per capita amount of nearly 1 million yuan. Among them, one was sentenced to life imprisonment and all his property was confiscated, and five were sentenced to more than 10 years of fixed-term imprisonment.

Tan Jinsong, President of the second criminal court of Beijing No.2 Middle School, analyzed and pointed out that the fraud of medical insurance fund involves many links, such as drug manufacturers, designated hospitals of medical insurance, prescription doctors, cardholders, and the discount of stolen money. Each link colludes with each other to defraud the medical insurance fund.

According to reports, the crime modes and types of defrauding medical insurance funds are usually as follows: staff members of medical institutions defraud medical insurance funds, falsely use other peoples medical insurance cards, prescribe a large number of drugs, collect medical insurance cards in large quantities, and illegally collect a large number of drugs.

According to the typical cases published by Beijing No.2 Middle School Hospital, a community health station is a designated medical institution for medical insurance in Beijing. From 2011 to 2017, Zhang, the legal representative of the health station, Wang, sun, sun, and Li, the head of the pharmacy, conspired to defraud more than 30 million yuan of medical insurance fund by means of forged drug warehousing registration, false entry of drug quantity and false registration. After trial, the court sentenced the defendant Zhang to life imprisonment, Wang to 14 years imprisonment, Li to three years imprisonment, and sun to three years imprisonment and three years probation.

According to Yang Ziliang, a judge of Beijing No.2 Middle School, some criminals collect a large number of medical insurance cards, go to the hospital to seek medical treatment under false names, and sell them at a higher price after falsely prescribing a large number of drugs; some people know that others use the medical insurance cards to conduct fraud and other criminal activities, and provide the collected medical insurance cards to others for use to earn rental fees or commission of medical insurance cards; some people are also specialized in fraud The downstream crime of the crime of obtaining drugs by medical insurance.

Such actors may conspire to defraud the medical insurance fund in advance, agree to purchase drugs afterwards, or purchase and distribute drugs with the knowledge that they are the proceeds of crime without prior conspiracy, or purchase drugs without obtaining the drug trading license. Yang Ziliang said.

Illegal prescribing medicine to drug dealers

According to tan Jinsong, only 3% of the cases (1 case) surrendered themselves, 11% of the cases (4 cases) were investigated after the governments medical insurance authorities found that individual medical insurance cards were used abnormally through the big data system, while 86% of the cases (30 cases) were reported and explained by the co investigators, and the phenomenon of one check, one string was obvious.

It is understood that the reasons for the reports and confessions in the cases are mostly due to the investigation and punishment of other crimes by the public security organs, or the confession after being summoned by the public security organs for suspected abnormal use of medical insurance cards.

According to the statistics of Beijing No.2 Middle School, the joint crime rate reached 97% (34 cases) and the individual crime accounted for 3% (1 case). The common criminals are familiar with family members, relatives, colleagues and so on. They teach criminal techniques and introduce the situation of upstream and downstream criminals. In terms of booty sharing, the principal offender shared more stolen money than the accomplice.

No matter what kind of medical insurance fraud is used, a large amount of medical insurance card consumption and cash out will eventually be required. Tan Jinsong said that according to relevant regulations, medical insurance cards can only be used by themselves. Those who rent or lend medical insurance cards should return funds according to law and be punished. Knowing that others commit fraud crimes, they still provide medical insurance cards, which constitutes a joint crime. However, some insured residents are indifferent to the legal consciousness and violate the legal provisions for hundreds of yuan and thousands of yuan, causing huge losses to the national health insurance fund.

At the same time, the phenomenon of fraudulently obtaining medical insurance fund also exposes the loopholes of illegal prescription and link system. Some doctors didnt check their identities when they prescribed medicine. In daily medical treatment, some elderly people who are unable to move will ask their relatives and friends to prescribe medicine on their behalf. Doctors usually do not review and record the identity of the person who prescribes drugs on behalf of them. Objectively, it is difficult to examine whether the person who prescribes drugs on behalf of them is relatives of the elderly. This gives professional drug dealers an opportunity to seek medical treatment under the false name.

There was no inter hospital investigation mechanism. According to the relevant regulations, the one-time prescribed dose of emergency medicine shall not exceed 3 days, generally not more than 7 days, and the patients mobility inconvenience shall not exceed 14 days. Drugs for chronic diseases such as hypertension and diabetes can be prescribed for one month at a time. However, in related cases, if there is an immediate joint investigation mechanism between different hospitals, it is difficult to prescribe a large number of drugs in a short time.

Guard against loopholes and manage personal medical insurance card

How to prevent loopholes and protect our life saving money? To avoid such cases?

Tan Jinsong suggested that we should strengthen the legal education for the insured residents, increase the administrative punishment for the card holders who illegally lend or rent the medical insurance card, and impose the punishment of suspending the medical insurance treatment for a period of time according to the situation. If the crime constitutes a crime, the criminal responsibility should be investigated, and the legal atmosphere of strict law enforcement and illegal investigation should be created to give full play to the general preventive role of law.

The judge also suggested that while strengthening the medical treatment measures, medical institutions should strictly implement the provisions of medical insurance prescription, and clarify the responsibility of doctors to prescribe medicine and verify their identity. For the situation of agent prescribing, we should make clear the identity of the agent prescribing agent, strictly implement the one-time prescribing amount, and try to prevent the occurrence of large amount of one-time prescription.

The investigation found that many drug dealers who illegally collected drugs and medical insurance cards were active in the vicinity of the hospital. There were many stall collecting cards at the gate of the hospital. Some pharmacies purchased drugs from informal channels for a long time.

The judge suggested that we should strengthen the inspection of law enforcement around hospitals and pharmacies, and prevent the breeding of crimes from the upstream and downstream of the crime of defrauding medical insurance funds. At the same time, the medical insurance bureau and other competent departments should further strengthen the construction of big data analysis. For example, we should use scientific and technological means to strengthen the screening and inspection of abnormal medical insurance cards, carry out dynamic big data management on drug manufacturers, hospitals, pharmacies and cardholders, build models, analyze abnormal dynamics, and ensure timely detection of relevant criminal clues.

Li Wanxiang

Source: Zhang Zutao, editor in charge of China economic network_ NT5054