The National Medical Security Administration recently announced the first batch of ***9 typical cases of medical insurance fraud this year, which include not only designated medical institutions, but also involving insured persons, medical institutions and medical insurance department staff Fraud and insurance fraud. So, what kind of legal liability should we bear for these various medical insurance frauds? The "Regulations on the Supervision and Management of the Use of Medical Insurance Funds" will be implemented in May this year. What are the regulations on the use, supervision, management and legal responsibilities of medical insurance funds? Medical insurance fraud can be punished criminally. As a kind of social insurance, medical insurance comes from a basic right of citizens stipulated in our country's constitution, that is, the right to material assistance. The state establishes a medical insurance system to enable the people to afford medical treatment, afford medicine, and stay healthy. However, some people have focused on this field to commit illegal acts of fraud and insurance fraud. Medical insurance fraud has always been an illegal act prohibited by legal regulations. In the early days of the development of social insurance in my country, because medical insurance was one of them, medical insurance fraud was included in social insurance fraud. According to Articles 87 and 88 of the "Social Insurance Law of the People's Republic of China", social security agencies, medical institutions, pharmaceutical business units and other social security service agencies use fraud, forged certification materials or other means to defraud social security fund expenditures Or if an individual defrauds social security benefits in the above-mentioned ways, the social security administrative department shall order the return of the defrauded social insurance benefits and impose a fine of not less than 2 times but not more than 5 times the amount defrauded; if it belongs to a social security service agency, the service agreement shall be terminated; the person in charge directly responsible and If other persons directly responsible have professional qualifications, their professional qualifications shall be revoked in accordance with the law. According to the provisions of Article 94, any violation of the above legal provisions that constitutes a crime shall be investigated for criminal responsibility in accordance with the law. In addition to social security agencies and social security service agencies such as medical institutions and pharmaceutical business units, as well as insured individuals, Article 27 of the "Labor Security Supervision Regulations" also stipulates the legal liability of employers for defrauding social insurance. If an employer conceals the total amount of wages or the number of employees when declaring the amount of social insurance premiums payable, the labor and social security administrative department shall order it to make corrections and impose a fine of not less than 1 time but not more than 3 times the amount of underreported wages. Anyone who defrauds social security benefits or defrauds social security fund expenditures shall be ordered by the labor and social security administrative department to return the money and impose a fine of not less than 1 time but not more than 3 times of the amount defrauded; if a crime is constituted, criminal liability shall be pursued in accordance with the law. Regarding the criminal liability for defrauding social insurance, those who defraud social insurance funds such as pension, medical care, work injury, unemployment, maternity, etc. or other social security benefits by fraud, forgery of certification materials or other means fall under the crime of fraud stipulated in Article 266 of the Criminal Law of our country. Fraudulent behavior of public and private property. According to the law, whoever defrauds public or private property and the amount is relatively large shall be sentenced to fixed-term imprisonment of not more than 3 years, criminal detention or surveillance, and may also or solely be fined; if the amount is huge or there are other serious circumstances, he shall be sentenced to fixed-term imprisonment of not less than 3 years but not more than 10 years. and shall also be fined; if the amount is particularly huge or there are other particularly serious circumstances, the person shall be sentenced to fixed-term imprisonment of not less than 10 years or life imprisonment, and shall also be fined or have property confiscated. In recent years, the particularity and importance of medical insurance have become increasingly prominent, and insurance fraud occurs from time to time. Various localities have issued corresponding local normative documents to regulate medical insurance fraud. However, because the above-mentioned documents have a low legal level and are less standardized, based on the pilot work of local normative documents, the State Council has adopted a separate law The "Regulations on the Supervision and Administration of the Use of Medical Security Funds" (hereinafter referred to as the "Regulations") were promulgated. As my country's first administrative regulations in the field of medical security, it will be officially implemented on May 1 this year. This regulation clearly stipulates the use, supervision, management and legal responsibilities of medical security funds, draws a "red line" and "bottom line" that cannot be touched for people's "medical treatment money" and "life-saving money", and has entered a new stage of the entire medical insurance system. The track of rule of law is of milestone significance. It is not uncommon for designated medical institutions to cheat on insurance or have their professional qualifications revoked. It is not uncommon for designated medical institutions to commit fraud and engage in insurance fraud. This mainly involves designated medical institutions and designated retail pharmacies. It is involved in 9 typical cases announced by the National Medical Security Administration.
For example, in the insurance fraud case of Jinjing Hospital in Jinzhou City, Liaoning Province, a joint investigation by the Jinzhou Municipal Medical Insurance Bureau and the Public Security Bureau found that Huang, the director of the hospital, together with many people inside and outside the hospital, borrowed employee, resident, and student medical insurance cards to use the hospital’s medical insurance system. He swiped his card for false hospitalization and defrauded the medical insurance fund of more than 2.9 million yuan. At present, all illegal funds in this case have been recovered and returned to the medical insurance account. The local court convicted Huang of fraud and sentenced him to 8 years and 8 months in prison and fined him 500,000 yuan. His co-defendants included the hospital's legal person Tian, ??doctor Xu, and financial staff Duan. Another example is the case of fraud and insurance fraud at Chunwang Hospital in Wangchengpo, Changsha City, Hunan Province. After investigation by the Changsha Municipal Public Security Bureau and the Medical Insurance Bureau, it was found that the vice president of the hospital, Li Mou, the president and legal person Liu, and others passed the test on drugs, laboratory tests, By manipulating traditional Chinese medicine packages and treatments, the police defrauded the medical insurance fund of more than 4.25 million yuan. After trial by the court, Liu and Li defrauded the national medical insurance fund, and the amount was extremely huge. Their actions constituted the crime of fraud. Liu was sentenced to 10 years in prison and fined 100,000 yuan respectively; Li was sentenced to 3 years in prison. 5 years probation and a fine of 70,000 yuan. Article 38 of the "Regulations" stipulates that designated medical institutions have any of the following circumstances, such as decomposed hospitalization, hanging bed hospitalization; excessive diagnosis and treatment in violation of diagnosis and treatment standards, excessive examinations, decomposed prescriptions, overprescription of medicines, repeated prescriptions, or other unnecessary provision Medical services; repeated charges, excessive charges, decomposed project charges; exchanging medicines, medical consumables, diagnosis and treatment items and service facilities; reselling medicines for insured persons to take advantage of their medical security benefits, accepting returns in cash, in kind or obtaining other benefits Providing convenience for illegal interests; including medical expenses that are not within the scope of payment of the medical security fund into the settlement of the medical security fund; and other illegal acts that cause losses to the medical security fund, the medical security administrative department shall order corrections and may interview the relevant person in charge; If the medical security fund is lost, it shall be ordered to return it and a fine of not less than 1 time but not more than 2 times the amount of the loss shall be imposed; if it refuses to make corrections or causes serious consequences, the designated medical institution shall be ordered to suspend the relevant responsible departments for not less than 6 months but not more than 1 year in relation to the medical security fund. Medical services used; violations of other laws and administrative regulations will be dealt with by the relevant competent authorities in accordance with the law. Article 40 stipulates that designated medical institutions defraud medical security fund expenditures through the following methods, such as inducing or assisting others to impersonate their names or falsely seek medical treatment or purchase medicines, provide false certification materials, or collude with others to falsely issue expense receipts; forge, alter, or conceal , altering or destroying medical documents, medical certificates, accounting vouchers, electronic information and other relevant materials; fabricating medical service items and other acts of defrauding medical security fund expenditures shall be ordered to be returned by the medical security administrative department, and a penalty of not less than 2 times but not more than 5 times of the amount defrauded shall be imposed fines; order designated medical institutions to suspend the medical services involving the use of medical security funds by relevant responsible departments for more than 6 months and less than 1 year, until the service agreement is terminated by the medical security agency; those who have practicing qualifications shall be revoked by the relevant competent authorities in accordance with the law qualifications. Since retail pharmacies have been included in the designated areas of medical insurance, fraud such as false registration of medicines, stolen medical insurance cards, and false purchases of medicines have occurred from time to time. Take the empty medical insurance card as an example. From October 2016 to April 2017, Ding used the social security and medical insurance cards of others and his relatives in the pharmacy company he opened, inflating the price of medicines by hundreds of times and using empty medical insurance cards. Defrauding medical insurance funds. As of the time of being seized, Ding's account had received more than 280,000 yuan in medical insurance funds, and the remaining more than 230,000 yuan had not yet been disbursed. The court believed that Ding's behavior constituted the crime of fraud and sentenced him to 3 years in prison, suspended for 3 years, and fined RMB 30,000. The illegal gains were returned to the victim unit. The maximum fine for insured persons who cheat on insurance is 5 times. Looking at the entire process of medical insurance collection and payment, the main subjects of fraud involve payment units and insured persons, which mainly occur in two stages: First, during the collection and payment of medical insurance funds For the purpose of evading payment obligations, payment units and insured persons forge or alter social security registration certificates, falsely declare the number of employees, paid wages and other information, forge, alter or deliberately destroy account book materials related to medical insurance payment or fail to establish The account books make it impossible to determine the base of medical insurance payment, etc.
Second, in the payment process of medical insurance funds, units and insured persons, for the purpose of defrauding medical insurance benefits, borrow or use identity certificates or social security cards in violation of regulations, forge or use false medical records and other medical documents and medical bills, and handle false admissions, etc. , causing losses to the medical insurance fund. For example, insured person Wang bought a set of fake medical records for 3,000 yuan and reimbursed them through the local medical insurance department, defrauding him of more than 50,000 yuan. After that, he purchased 5 sets of fake medical records in the same way, 4 of which were reimbursed for more than 480,000 yuan. The medical insurance department discovered the fraud during the review of the last one and reported the case. The court held that Wang, for the purpose of illegal possession, defrauded the national medical insurance funds many times by purchasing false hospital records and invoices for reimbursement, and the amount was particularly huge. His behavior constituted the crime of fraud, and he was sentenced to ten years in prison and fined. 20,000 yuan in gold. Article 41 of the "Regulations" stipulates that if an individual gives his or her medical security certificate to others for false use; repeatedly enjoys medical security benefits; takes advantage of the opportunity to enjoy medical security benefits to resell drugs, accepts return of cash or in kind, or obtains other illegal benefits In one of the circumstances, the medical security administrative department shall order correction; if it causes losses to the medical security fund, it shall be ordered to return it; if it is an insured person, the online settlement of medical expenses shall be suspended from 3 months to 12 months. If an individual commits one of the acts specified in the preceding paragraph with the purpose of defrauding the medical security fund, causing losses to the medical security fund; or uses other people's medical security certificates to seek medical treatment or purchase medicines under his/her name; or forges, alters, conceals, alters, Anyone who destroys medical documents, medical certificates, accounting vouchers, electronic information and other relevant materials or fabricates medical service items to defraud medical security fund expenditures shall, in addition to being handled in accordance with the provisions of the preceding paragraph, be punished by the medical security administrative department for twice the amount defrauded. A fine of more than 5 times but not more than 5 times. Article 4 of the General Provisions of the "Regulations" stipulates that "the supervision and management of the use of medical security funds shall be implemented through a combination of government supervision, social supervision, industry self-discipline and personal trustworthiness." The distinctive social law characteristics of the medical security system require the multi-pronged approach and joint participation of the government, society, industry and individuals, in order to give full play to the function of the medical insurance fund in ensuring that the people have access to medical care. Strengthen government supervision. The "Regulations" clarify that the people's governments at or above the county level lead the supervision and management of the use of medical insurance funds. The National Medical Security Administration is responsible for the supervision of medical insurance funds nationwide, and the departments of medical security, health, traditional Chinese medicine, market supervision and management, finance, auditing, and public security There should be division of labor and mutual cooperation, and the medical security administrative department may also entrust organizations that meet statutory conditions to carry out medical insurance administrative law enforcement in accordance with the law. Strengthen social supervision. The "Regulations" stipulate that the state encourages and supports the news media to carry out public welfare publicity of medical security laws, regulations and knowledge, and at the same time conducts public opinion supervision on the use of funds. Administrative departments should also listen to opinions from all walks of life by soliciting opinions in writing, holding symposiums, etc., open channels for reporting and complaints, and encourage and support supervision by all parties in society. Strengthen industry self-discipline. Designated medical institutions and units should strengthen self-discipline and restraint, prudently diagnose, treat and prescribe medicines, so that people who are truly sick can afford to see a doctor and take medicines. Medical and health industry associations should also strengthen industry standards, promote industry self-discipline, and guide the legal and rational use of medical security funds. Call on individuals to be trustworthy. Since the payment and payment of medical insurance funds require individual participation and activation, personal credit plays an important role in the supervision of medical insurance funds. Integrity in participating in insurance and reimbursing in good faith are the responsibilities and obligations of every insured person, and they are also the source of healthy development of the medical security system. Legal basis:
"Interim Provisions on Medical Security Administrative Penalty Procedures"
Article 1 is to standardize the administrative penalty procedures in the field of medical security, ensure that the medical security administrative department implements administrative penalties in accordance with the law, and safeguard medical care. To ensure the security of the fund and protect the legitimate rights and interests of citizens, legal persons and other organizations, these regulations are formulated in accordance with the "Administrative Punishment Law of the People's Republic of China", the "Administrative Enforcement Law of the People's Republic of China" and other laws and administrative regulations.
Article 2: Administrative penalties in the field of medical security shall apply to these regulations.
Article 3 The medical security administrative department shall follow the principles of fairness and openness when implementing administrative penalties.
Adhere to the fact-based basis and be commensurate with the facts, nature, circumstances and degree of social harm of the illegal act. We must adhere to the combination of punishment and education to ensure that the facts are clear, the evidence is conclusive, the basis is correct, the procedures are legal, and the punishment is appropriate.
Article 4: The medical security administrative department shall fully implement the administrative law enforcement publicity system, the entire law enforcement process recording system, and the legal review system for major law enforcement decisions.
Article 5 Law enforcement personnel who have a direct interest in the case or have other relationships that may affect fair law enforcement should recuse themselves.
If the parties believe that the law enforcement personnel have a direct interest in the case or have other relationships that may affect fair law enforcement, they have the right to apply for recusal.
If a party files an application for withdrawal, the medical security administrative department shall review it in accordance with the law. The withdrawal of the main person in charge of the medical security administrative department shall be decided by the collective discussion of the person in charge of the medical security administrative department; the withdrawal of other persons in charge of the medical security administrative department shall be decided by the main person in charge of the medical security administrative department; the withdrawal of other relevant personnel shall be decided by the medical security administrative department The head of the administrative department decides. The investigation will not stop until a decision is made.
Article 6: If an illegal act is not discovered within two years, no administrative penalty will be imposed; if it involves the life, health and safety of citizens and has harmful consequences, the above period is extended to five years.
The period specified in the preceding paragraph shall be calculated from the date of the occurrence of the illegal act; if the illegal act has a continuous or continuing state, it shall be calculated from the date of termination of the act.
Article 7 The higher-level medical security administrative department shall strengthen supervision over the administrative penalties imposed by the lower-level medical security administrative department.
The legal agencies of the medical security administrative departments should strengthen supervision over the administrative penalties imposed by their own departments.
Article 8 Medical security administrative departments at all levels may entrust organizations that meet statutory conditions to carry out administrative law enforcement work in accordance with the law. The power of administrative compulsory measures shall not be delegated.
The entrusted organization shall implement administrative penalties in the name of the entrusting administrative agency within the scope of entrustment, and shall not entrust other organizations or individuals to implement administrative penalties.
The power of attorney shall specify the specific matters entrusted, authority, time limit, etc. The entrusting administrative agency and the entrusted organization shall publish the letter of authorization to the public.
The entrusted administrative agency shall be responsible for supervising the implementation of administrative penalties on the entrusted organization and shall bear legal responsibility for the consequences of such behavior.