Original title: Who is using the “life-saving money” for China‘s three-year recovery of more than 34 billion medical insurance funds?
Chinanews client, Beijing, October 9th (Reporter Zhang Ni) In recent years, with the improvement of the national medical security system, the coverage of medical insurance and the scale of funds have continued to expand, and the risk points have also increased. Fraud of medical security funds is illegal. Crime is high and frequent.
According to data from the National Medical Insurance Administration, from 2018 to 2020, the National Medical Insurance Administration and other relevant departments have recovered a total of 34.875 billion yuan in medical insurance funds. Who on earth is touching the people’s “life-saving money”?
——Prescribing more medicines and consumables, the hospital staff will get a commission of 300 yuan for each patient introduced
On the 8th, the Ministry of Public Security and the National Medical Security Administration jointly held a press conference on the special rectification action against fraudulent insurance. The results of a series of special rectification actions were announced at the meeting, as well as the details of some fraudulent insurance cases.
Li Yinan, deputy director of the Criminal Investigation Bureau of the Sichuan Provincial Public Security Department, disclosed that at the beginning of this year, the public security agency in Dazhou City, Sichuan Province, based on clues handed over by the Commission for Discipline Inspection and Supervision, successfully dismantled the criminal gang of fraudulent medical insurance funds under the guise of Xuanhan County Mintai Hospital, and arrested including hospitals. Forty-seven criminal suspects, including the director, froze more than 1.4 million yuan of funds involved in the case, and seized a large number of false medical records, accounting books and other items involved in the case. The amount involved was as high as 11 million yuan.
After investigation, Xuanhan County Mintai Hospital has applied for more than 10.73 million yuan in medical insurance funds from the Medical Insurance Bureau. Since being included in the designated medical insurance institution in May 2018, the criminal gang headed by Wang Moucai, the director of the Mintai Hospital of Xuanhan County, began to organize illegal and criminal activities to defraud the medical insurance fund under the cover of the hospital. .
According to reports, the scam group is closely organized and has a clear division of labor. In order to defraud the medical insurance fund for illegal profit, the whole process of the hospital is fraudulent. The marketing department uses rigid indicators to pull patients to find resources. The hospital staff earns 300 yuan for each patient introduced.
Doctors prescribe falsely, prescribe more drugs and check items for diagnosis and treatment, falsify medical records, prescribe more days of hospitalization and empty beds; the laboratory modifies the index of patient inspection coefficients to achieve the purpose of defrauding patients for hospitalization; the nursing department fabricates nursing records and executes false orders , False billing, destruction of more medicines and consumables; the hospital office is responsible for organizing medical insurance medical records in accordance with the reporting requirements, reporting national medical insurance funds, and the medical insurance funds obtained from fraud are used to pay for the daily operating costs of the hospital, and all are used for shareholder dividends and commissions from the marketing department .
-Criminals purchase medical insurance drugs from patients at a low price
Prior to this, the Shanghai public security organs also succeeded in destroying a group of criminal gangs that illegally sold medical insurance drugs.
Yu Meng, head of the Food and Drug Environmental Investigation Team of the Shanghai Public Security Bureau, introduced at the meeting that in January this year, through the execution connection mechanism with the Shanghai Medical Insurance Bureau, the Medical Insurance Bureau transferred relevant clues and found that there were abnormal behaviors in multiple medical insurance accounts that did not meet the requirements. Normal medication needs.
The public security organs used big data to analyze and make judgments, and locked more than 200 high-risk medical insurance accounts with payment abnormalities and suspected paid loans of falsely prescribed drugs, and then further investigated and collected evidence through the accounts, and verified the use of the above medical insurance cards to falsify medical conditions and fraudulently prescribe them. There are more than 100 “pharmaceutical dealers” for medical insurance drugs, and two private outpatient clinics that collude with the drug dealers.
On this basis, in April and June of this year, with the cooperation of the Shanghai medical insurance department, the task force carried out 2 centralized network collection operations and successfully solved the series of cases.
According to investigations, since the beginning of 2020, in order to seek illegal benefits, criminal gang members headed by Chi have been squatting at the door of many hospitals in Shanghai for a long time, purchasing medical insurance drugs from patients at a price of 30 to 50%. At the same time, criminals have also been illegal. Purchasing other people’s medical insurance cards to Shanghai hospitals, pharmacies and other medical insurance designated medical institutions to pretend to use others’ identities to defraud drugs, in this way to hoard a large amount of supply of drugs.
In order to seek higher illegal benefits, one of the criminal suspects also directly colluded with two private outpatient clinics in Shanghai, by falsely issuing drug receipts and fraudulently issuing high-priced Chinese herbal medicines, swiping the medical insurance card in the hospital and directly defrauded the medical insurance fund. , And at the same time sell the drugs that were tricked out at high prices.
——The regulatory situation for recovering more than 34 billion medical insurance funds in three years is still grim
The reporter learned from the meeting that in recent years, the national medical security system has been continuously improved, with the coverage of medical insurance reaching 1.361 billion people and the scale of funds reaching 3.1 trillion yuan. Strengthening the supervision and management of the medical insurance fund is to protect the people’s “life-saving money.”
Duan Zhengming, deputy director of the Fund Supervision Department of the National Medical Insurance Administration and second-level inspector, said at the meeting that since the establishment of the National Medical Insurance Administration, it has always taken the fight against fraudulent insurance as its primary task, and has initially established a high-pressure situation to combat medical insurance fraudulent insurance. , The widespread and frequent occurrence of medical insurance fraud cases has been initially curbed, and the supervision of medical insurance funds has achieved certain results. From 2018 to 2020, a total of 1.71 million designated medical institutions were inspected, 860,000 were investigated and dealt with, and 34.875 billion yuan of medical insurance funds were recovered.
However, he emphasized that the supervision situation of medical insurance funds is still severe, and insurance fraud cases still occur from time to time. For example, fraud cases in Taihe County, Anhui Province and Cheng’an County, Hebei Province have aroused widespread public concern. This once again warns that the task of combating fraudulent insurance is still very arduous and requires constant attention.
The reporter learned that on April 9 this year, the Ministry of Public Security, in conjunction with the National Medical Insurance Administration, the National Health Commission and other departments, jointly deployed a special rectification action against fraudulent insurance in accordance with the law. As of the end of September, public security organs across the country have eliminated 251 criminal gangs, arrested 3,819 criminal suspects, uncovered 1,246 cases of medical insurance fund fraud, recovered 230 million medical insurance funds, and united medical insurance departments to shut down and handle 277 medical institutions. (over)