What are the three fakes, fraud and insurance fraud?

The three fakes in fraudulent insurance fraud are: false patient, false illness and fraudulent insurance fraud with false bills.

Insurance fraud is also called insurance crime internationally. Strictly speaking, insurance fraud has a wider meaning than insurance crime, and both parties to the insurance may constitute insurance fraud.

1. Fraud and insurance fraud

1. Illegal profit-making by using medical insurance vouchers

It is strictly forbidden to use medical insurance cards to buy and sell pharmaceutical consumables and make illegal profits. If the above-mentioned illegal acts are found, the illegal expenses will be recovered, fined 2-5 times, and transferred to judicial organs according to law.

2. Lend the medical insurance to others or seek medical treatment under an assumed name

It is forbidden for the insured to lend his medical insurance certificate to others or seek medical treatment under an assumed name with the medical insurance certificate of others. If the above-mentioned illegal acts are found, the illegal expenses will be recovered, and the insured person will be suspended from using the medical insurance card for settlement. If the circumstances are serious, a fine of 2-5 times will be imposed.

3. The medical insurance card illegally pays cash or buys food and daily necessities.

It is strictly forbidden to collude with the insured to exchange cash or buy food and daily necessities to defraud the medical insurance fund. If the above-mentioned illegal acts are found, the illegal expenses will be recovered, the medical insurance designated service agreement will be terminated, and the insured will be suspended from using the medical insurance card for settlement.

4. include the medical expenses that should be borne by individuals in the payment scope of medical insurance fund

it is strictly forbidden for individuals to add the medical expenses that should be borne by individuals into the payment scope of medical insurance fund.

if the above-mentioned illegal acts are found, the illegal expenses will be recovered, and the insured will be suspended from using the medical insurance card for settlement. If the circumstances are serious, they will be transferred to the judicial organs according to law.

5. Fictitious medical services, forged medical documents and bills

It is strictly forbidden for designated medical institutions to defraud medical insurance funds through fictitious medical services, forged medical documents and bills.

if illegal behaviors are found, the illegal expenses will be recovered, the designated medical insurance service agreement will be terminated, and the criminal responsibility of the medical staff involved and the relevant person in charge of the hospital will be investigated according to law.

6. Swapping medicines, consumables, articles and medical treatment items

It is strictly forbidden for designated medical institutions to defraud medical insurance funds by swapping medicines, consumables, articles and medical treatment items.

if the above-mentioned illegal acts are found, the illegal expenses will be recovered and a fine of 2-5 times will be imposed. If the circumstances are serious, the designated medical insurance service agreement will be terminated.

7. Pretending to be hospitalized by case interpretation method:

Designated medical institutions are strictly prohibited from being hospitalized in name. If illegal appeals are found, the illegal expenses will be recovered. If the circumstances are serious, the designated medical insurance service agreement will be terminated and a fine of 2-5 times will be imposed.

II. Punishment Measures for Medical Fraud and Insurance Fraud

If the designated medical institution is found to have fraudulent insurance fraud, the medical insurance department shall order it to return the medical insurance fund and impose a fine of more than 2 times and less than 5 times the amount defrauded; Ordering the designated medical institutions to suspend the designated medical insurance service or terminate the service agreement; The relevant medical personnel of designated medical institutions shall be punished by the health department according to law; The directly responsible person in charge and other directly responsible personnel shall be dealt with according to the law and regulations.

if social insurance agencies, medical institutions, pharmaceutical trading units and other social insurance service institutions defraud social insurance fund expenditures by fraud, forgery of certification materials or other means, the social insurance administrative department shall order them to return the defrauded social insurance money and impose a fine of not less than two times but not more than five times the amount defrauded; If it belongs to a social insurance service institution, the service agreement shall be terminated; If the directly responsible person in charge and other directly responsible personnel have professional qualifications, their professional qualifications shall be revoked according to law.

Legal basis

Article 4 of the Regulations on the Supervision and Administration of the Use of Medical Insurance Funds, if a designated medical institution defrauds the medical insurance funds in the following ways, the administrative department of medical insurance shall order it to return it and impose a fine of more than 2 times and less than 5 times the amount defrauded; Ordering the designated medical institutions to suspend the medical services involved in the use of medical insurance funds by the relevant responsible departments for more than 6 months and less than 1 year, until the medical insurance agency terminates the service agreement; (1) Inducing and assisting others to take false names or purchase medicines, providing false certification materials, or colluding with others to falsely make out expense documents;

(2) forging, altering, concealing, altering or destroying medical documents, medical certificates, accounting vouchers, electronic information and other relevant materials;

(3) fictitious medical service projects;

(4) other acts of defrauding medical insurance fund expenditures.

if a designated medical institution commits one of the acts specified in article 38 of these regulations for the purpose of defrauding the medical security fund, it shall be dealt with in accordance with the provisions of this article.