2023 is the year of medical insurance fund supervision and safety regulation. In this issue, the exposure desk of Shanxi Medical Insurance Bureau selected 7 typical cases of illegal activities of designated medical institutions and 5 typical cases of personal insurance fraud for exposure, which involved fictitious medical services, forged medical records, induced hospitalization, unreasonable diagnosis and treatment, and the purchase, sale and storage of pharmaceutical consumables did not conform to the illegal activities such as impersonation, repeated enjoyment of treatment, and concealment of third-party responsibilities. The above-mentioned violations of laws and regulations by medical institutions and individuals have caused the loss of medical insurance funds and had a negative impact on society. The majority of designated medical institutions and insured persons should strictly abide by the Regulations on the Supervision and Administration of the Use of Medical Security Funds and the Measures for the Supervision and Administration of the Use of Medical Security Funds in Shanxi Province, resolutely put an end to illegal acts and promote the healthy and sustainable development of the medical security system in the province.
1. Case of illegal use of medical insurance fund in Zhanghe Renji Hospital, Zhangzi County, Changzhi City??
In October, 2020, Changzhi Medical Security Bureau found that there were fictitious medical service projects and forged hospitalization medical records in Zhanghe Renji Hospital in Zhangzi County, which were suspected of defrauding the medical insurance fund. The above acts involved the illegal use of medical insurance fund of 105,311.39 yuan. According to "People’s Republic of China (PRC) Social Insurance Law" and "Service Agreement of Designated Medical Institutions for Basic Medical Insurance in Zhangzi County", the local medical insurance department handled the results as follows: 1. Ordered to return the lost medical insurance fund and imposed twice the administrative fine; 2. Dissolve the medical insurance service agreement signed with the hospital; 3. Transfer the case materials and clue information of forged hospitalization medical records and other suspected fraudulent medical insurance funds to the local public security organs for investigation and handling according to law. In July 2022, after the trial by the Intermediate People’s Court of Changzhi City, Shanxi Province, Bao Moumou, a legal person of the court, was sentenced to four years and ten months in prison. At present, the lost medical insurance fund of 105,311.39 yuan has been fully recovered, and the administrative fine of 210,622.78 yuan has been fully paid.
2. Case of illegal use of medical insurance fund by Sumin Traditional Chinese Medicine Rheumatoid Hospital in Yanhu District, Yuncheng City
In January, 2021, the Medical Security Bureau of Yanhu District of Yuncheng City found that there were some irregularities in the hospital, such as induced hospitalization, low-standard hospitalization, unreasonable examination and treatment, irregular hospital management, and incomplete records of Chinese herbal medicines, which involved the illegal use of medical insurance funds of 18,073.63 yuan. According to the Service Agreement of Designated Medical Institutions for Basic Medical Insurance in Yuncheng City, the local medical insurance department handled the following results: 1. Refusing to pay the medical insurance expenses incurred in January 2021, recovering the lost medical insurance fund, and giving 5 times of liquidated damages; 2. terminate the medical insurance service agreement. At present, the lost medical insurance fund of 18,073.63 yuan and five times the liquidated damages of 90,368.15 yuan have all been recovered.
Three, Taiyuan Xishan Coal and Electricity Workers General Hospital illegal use of medical insurance fund case.
In January, 2022, Taiyuan Medical Security Bureau found that three tumor patients in the hospital used recombinant human growth hormone without a doctor’s prescription, and the drugs were directly received by the staff of the hospital, involving illegal use of the medical insurance fund of 232,849.87 yuan. According to "People’s Republic of China (PRC) Social Insurance Law" and "Medical Service Agreement of Taiyuan Designated Hospital with Basic Medical Insurance in 2021", the results of the local medical insurance department are as follows: 1. Recover the illegally used medical insurance fund and deduct 2 times the liquidated damages; 2. Transfer the case materials and clue information suspected of defrauding the medical insurance fund to the local public security organ for investigation and handling according to law. At present, the lost medical insurance fund of 232,849.87 yuan and twice the liquidated damages of 465,699.74 yuan have all been recovered.
4. Case of illegal use of medical insurance fund by Wankangtang Pharmaceutical Co., Ltd. in Yaodu District, Linfen City
In July, 2021, the Medical Security Bureau of Yaodu District, Linfen City found that there were some irregularities in the pharmacy, such as changing the drug list, inconsistent purchase, sale and storage, involving the illegal use of medical insurance fund of 3,351.8 yuan. According to the Regulations on the Supervision and Administration of the Use of Medical Insurance Funds and the Service Agreement of Designated Retail Drugstores for Basic Medical Insurance in Yaodu District, the local medical insurance department handled the following results: 1. Refusing to pay the illegal fees and imposing a penalty of 1 time; 2. Suspending the medical insurance service agreement for 1 month. At present, the lost medical insurance fund of 3,351.8 yuan and liquidated damages of 3,351.8 yuan have all been recovered.
V. Shanxi, Datong CityGuodaWanmin Pharmacy Chain Co., Ltd. Datong Yujinyuan Store used medical insurance fund illegally.
In September, 2021, Datong Medical Security Bureau received a report clue from the "12345" government service hotline, reflecting that Datong Yujinyuan Store of Shanxi Guoda Wanmin Pharmacy Chain Co., Ltd. was suspected of illegally using medical insurance funds, involving 301.96 yuan of illegal funds. After verification, the store violated the rules of selling health food by swapping drugs. According to the Service Agreement of Designated Retail Pharmacy of Datong Basic Medical Insurance, the local medical insurance department handled the following results: 1. Refused to pay the illegal fees of the pharmacy and imposed a penalty of 5 times; 2. terminate the service agreement. At present, the lost medical insurance fund of 301.96 yuan and five times the liquidated damages of 1509.8 yuan have all been recovered.
Six, Shuozhou Kangli Pharmacy Chain Co., Ltd. Huaiyi West Street Store illegally used the medical insurance fund case.
In October, 2020, Shuozhou Medical Security Bureau found in the daily inspection of the designated medical institutions that the pharmacy had some irregularities such as drug exchange, inconsistent purchase, sale and storage, involving the illegal use of the medical insurance fund of 4,185 yuan. According to the Service Agreement of Designated Retail Pharmacy of Shuozhou Basic Medical Insurance, the local medical insurance department handled the following results: 1. Refused to pay the illegal fees and imposed a penalty of 3 times. At present, the lost medical insurance fund of 4,185 yuan and liquidated damages of 12,555 yuan have all been recovered.
Seven, Xinzhou ningwu county Fukang pharmacy illegal use of medical insurance fund case.
In June, 2022, ningwu county Medical Insurance Bureau of Xinzhou City received a report clue, which reflected the illegal use of medical insurance funds in ningwu county Fukang Pharmacy. After verification, the drugs such as Bufei Pills and Shujin Jianyao Pills in this pharmacy are inconsistent in purchase, sale and storage, and the number of outbound drugs is greater than the number of inbound drugs, involving the illegal use of medical insurance funds of 8932 yuan. According to the Service Agreement of Designated Retail Pharmacy for Basic Medical Insurance in Xinzhou City, the results of local medical insurance departments are as follows: 1. Interview the person in charge of the pharmacy; 2. Order rectification within a time limit; 3. Recover the illegal expenses and impose a penalty of 2 times. At present, the lost medical insurance fund of 8,932 yuan and liquidated damages of 17,864 yuan have all been recovered.
Eight, Lvliang fangshan county Zhang Moumou insurance fraud case.
In December, 2020, the Audit Office of Shanxi Province found that Zhang Moumou, an insured person in fangshan county, had died in early 2018, but his medical insurance card still had chronic disease expenses paid by credit card. The Audit Office of Shanxi Province handed over the clues of the case to Lvliang Medical Security Bureau for further verification. It was verified that during the period from November 19 to December 23, 2018, Zhang Moumou’s husband used his medical insurance card to settle the chronic disease expenses five times, involving illegal use of the medical insurance fund of 10,334.8 yuan; In 2021, fangshan county Medical Insurance Bureau repeatedly asked Zhang Moumou’s husband to return the illegal medical insurance fund to no avail. According to "People’s Republic of China (PRC) Social Insurance Law", the local medical insurance department handled the following results: 1. Ordered to return the medical insurance fund used illegally; 2. Transferred the case materials and clues of the suspected fraudulent medical insurance fund to the local public security organ for investigation and handling according to law. According to the Criminal Law of People’s Republic of China (PRC) and the Interpretation of the Supreme People’s Court and the Supreme People’s Procuratorate on Several Issues Concerning the Specific Application of Law in Handling Criminal Cases of Fraud, on January 26, 2022, the People’s Court of fangshan county, Shanxi Province made a judgment according to law, and the defendant Zhang Moumou was sentenced to three months’ criminal detention, suspended for six months and fined 1,000 yuan. At present, the lost medical insurance fund of 10334.8 yuan has been fully recovered.
9. Sun Moumou’s insurance fraud case in Xing County, Luliang City
At the end of August 2020, the Xingxian Medical Insurance Bureau of Luliang City received a report, reflecting that the insured Sun Moumou was suspected of using the medical insurance fund in violation of regulations. After verification, Sun Moumou’s trauma was caused by the collapse and crushing of his employer Wang Moumou while digging the keel in the village, and then he provided false hospitalization documents and was hospitalized in Shanxi Grand Hospital. The hospitalization medical expenses were 238,063 yuan. On December 5, 2019, Sun Moumou instructed his son to conceal the third-party responsibility and apply for medical insurance reimbursement at Xingxian Medical Insurance Service Center, involving the illegal use of medical insurance funds of 196,779.99 yuan. According to "People’s Republic of China (PRC) Social Insurance Law", the local medical insurance department made the following decisions: 1. Ordered to return the illegally used medical insurance fund; 2. Transferred the case materials and clues of the suspected fraudulent medical insurance fund to the local public security organ for investigation and handling according to law. According to the Criminal Law of People’s Republic of China (PRC), on December 22, 2022, Xingxian People’s Court made a judgment according to law. The defendant Sun Moumou was convicted of fraud, sentenced to three years’ imprisonment, suspended for four years, and fined 5,000 yuan. At present, the lost medical insurance fund of 196,779.99 yuan has been fully recovered.
X. Cao Moumou’s insurance fraud case in Shouyang County, Jinzhong City
In June 2021, the Medical Insurance Bureau of Shouyang County, Jinzhong City received an investigation letter from Pingshu Township Government of Shouyang County, reflecting the problem of illegal reimbursement of medical insurance funds by urban and rural residents Cao Moumou. After verification, Cao Moumou fell off the water cart and injured himself while helping the villagers with their marriage. During the period from May 20, 2019 to June 9, 2019, he concealed the injured facts and provided false hospitalization proof materials, which violated the trauma reimbursement policy and enjoyed medical insurance benefits, involving illegal use of medical insurance funds of 9,550 yuan. According to the Social Insurance Law of People’s Republic of China (PRC), the local medical insurance department handled the following results: Cao was ordered to return the illegally used medical insurance fund. Cao Moumou has a good attitude of admitting mistakes, and actively and quickly returned all the 9,550 yuan of medical insurance funds illegally used to the medical insurance fund account.
Eleven, Yangquan City Huo Moumou fraud case.??
In September, 2021, Yangquan Medical Security Bureau received a report clue, reflecting that Huo Moumou (dead), an insured person in Yangquan City, was suspected of providing false reimbursement materials to defraud the medical insurance fund. After verification, Huo Moumou was hospitalized in Zaoqiang County People’s Hospital from January 26, 2018 to February 25, 2018, and directly settled the medical expenses of 46,548.8 yuan, of which the medical insurance fund paid 27,567.32 yuan. On April 23, 2018, Xu Moumou, the agent, manually reimbursed 33,334.85 yuan of medical expenses at the same time in Yangquan Medical Insurance Management Service Center, which was illegal to provide false reimbursement materials and repeatedly enjoy medical security benefits. According to the Social Insurance Law of People’s Republic of China (PRC), the local medical insurance department handled the following results: 1. Ordered to return the fraudulent medical insurance fund, 2. Suspended the online settlement of medical expenses for 12 months, and 3. Transferred the materials and clues of the suspected fraudulent medical insurance cases that provided false reimbursement materials to the local public security organs for investigation and handling according to law. At present, the lost medical insurance fund of 33,334.85 yuan has been fully recovered.
twelveThe case of Chang Moumou defrauding insurance in Yangcheng County, Jincheng City
On July 8, 2022, Jincheng Medical Insurance Bureau received an anonymous report that Chang’s medical insurance violation reimbursement was suspected of defrauding the medical insurance fund. On July 29th, 2022, before the on-the-spot investigation by the medical insurance department of Yangcheng County, Chang Moumou went to Yangcheng County Medical Insurance Bureau to apply for reimbursement of medical insurance expenses, and admitted that he was working for Yin Mou (Yin Mou contracted the meeting room project of Nanliu Village Committee) and accidentally fell off the colored steel plate in the car and was injured. Then he concealed the fact of the injury and provided false hospitalization certificates to Jincheng Jindong Orthopedic Hospital for medical treatment, enjoying medical insurance benefits in violation of the trauma reimbursement policy, which involved the illegal use of medical insurance funds. According to the "Regulations on the Supervision and Administration of the Use of Medical Insurance Funds", the results of the local medical insurance department are as follows: 1. Refund the illegal reimbursement of medical insurance funds; 2. Suspend the online settlement of Chang’s medical expenses for 6 months; 3. The case materials and clues of providing false hospitalization certificates to defraud the medical insurance fund were transferred to the local public security organs for investigation and handling according to law. At present, the lost medical insurance fund of 9199.40 yuan has been fully recovered.
Original title: Typical cases exposed by the exposure desk of Shanxi Medical Security Bureau in the first phase in 2023 (12 cases)
Editor: Jin Xuanyu
Editor: Xiao Ling
Audit: Wang Cheng
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