医保基金如何成“生意”？揭秘医保骗保“黑色产业链”

Core Viewpoint - The article discusses a significant case of medical insurance fraud in Datong, Shanxi Province, where a hospital was involved in fraudulent activities to illegally obtain funds from the national medical insurance system, highlighting the serious implications for public trust and the integrity of the healthcare system [1][15]. Summary by Sections Fraud Methods - Method 1: Increasing Fake Inpatients The hospital recruited patients, offering referral fees to those who brought in new patients, thereby inflating the number of hospital admissions [2][3]. - Method 2: Phantom Admissions Some patients did not actually stay in the hospital but left their insurance cards with the hospital, which then fabricated medical records and treatment documents to claim reimbursements [3][4]. - Method 3: Inflating Treatment Costs The hospital manipulated treatment records to elevate costs to the maximum reimbursement limit, even for minor ailments, by adding unnecessary treatments and medications [7][9]. - Method 4: Financial Fraud The hospital engaged in financial misreporting by inflating the costs of medications and treatments, submitting false data to the insurance system to claim higher reimbursements than actual expenses [11][13][17]. Legal Consequences - The main perpetrator, Ai Mouzhong, was sentenced to 13 years and 6 months in prison, with fines imposed on him and other co-defendants, reflecting the severity of the fraud and its impact on the healthcare system [18].