哪里出问题，就从哪里发力。针对这些骗保案件的特点，要加大惩处力度，精准发力，堵住漏洞，如医 保、市场监管等部门需强化联动，运用大数据等技术手段，对定点药店的结算数据实时预警、精准筛 查、突击检查，让违规者无所遁形。在这一过程中，监管必须全链条"长牙带刺"，惩戒必须"伤筋动 骨"。一旦查实，对违规药店应坚决取消其定点资格，并处以重罚；对涉事企业也要严惩，令其吐出非 法利润。同时，也要不断创新探索医保个人账户"活化"路径，如推行家庭共济、试水衔接长期护理保险 等，充分提升资金使用效率。 医保基金的每一分钱，都需要精准用在健康保障的"刀刃"上。护好守紧这些"看病钱""救命钱"，就是守 护我们的安康生活。共同织牢医保基金的"安全网"，让"救命钱"真正用于救命，才是对自己负责、对社 会负责。 海报制作：陈泉伊、刘羿佟 这种恶劣做法，不仅"刷"出了法律风险，也"刷"出了层层失守。从报道可知，上海警方公布的一起案例 中，涉事医院管理层、医生、"黄牛"等内外勾结，通过"黄牛"带诊、虚假诊疗等方式，两年内骗保记录 达到5万余条，骗取国家医保基金超过1200万元。仅这一案例的"黑色利益链"上，就有120多名犯罪嫌疑 人被采取刑事 ...

医保基金监管已覆盖"参保人—医疗机构—医药代表—药贩子—药店"完整非法利益链条。 从江西医药代表中药配方颗粒行贿案，上海医疗耗材商行贿案、医药代表篡改检测报告骗保案曝光，到 鞍山某医院药剂科主任受贿落马，再到上海退休人员王某涉及的药品倒卖"黑色产业链"被斩断，10余天 内国家医保局连续公布了5起涉及医保基金的典型案件。 这些案件清晰地表明，医保基金监管已经覆盖到了"参保人—医疗机构—医药代表—药贩子—药店"完整 非法利益链条。 北京中医药大学卫生健康法治研究与创新转化中心主任邓勇对第一财经表示，国家医保局密集公布这些 司法案例，释放出了对医疗腐败零容忍且严惩不贷、聚焦医保基金全链条守护、固化常态化监管机制这 三大核心信号。 医保局曝光医药购销贿赂案例 11月20日，25日，28日，国家医保局以"根据法院刑事判决书摘录"的形式连续公布了"黄某云涉中药配 方颗粒行贿案""上海某科贸商行涉支架球囊行贿案""鞍山市双山医院药剂科主任刘某红受贿案"的违法 犯罪细节。 邓勇表示，这些案例表明对医疗腐败零容忍且严惩不贷。不管是医药代表骗保及医疗耗材代理商行贿被 判刑，都体现司法层面从重处罚的态度，即便有自首、退赃等情节，也 ...

Core Insights - The article discusses the efforts of Yiwu City in Zhejiang Province to address issues related to the management and use of medical insurance funds, focusing on combating corruption and ensuring proper fund utilization [1][2] Group 1: Regulatory Measures - Yiwu City has established a collaborative mechanism involving multiple departments such as medical insurance, health, public security, and civil affairs to enhance the management of medical insurance funds [1] - The city is utilizing big data analytics through a provincial smart medical insurance supervision platform to monitor key risk points dynamically, improving the precision of regulatory efforts [1] Group 2: Case Studies and Findings - A specific case was highlighted where a warning from the big data analysis model indicated potential fraudulent behavior at a rehabilitation hospital, leading to a prompt investigation that prevented duplicate payments from the civil affairs system [1] - The city has mandated the rehabilitation hospital to improve internal management and has conducted multiple inspections to address violations related to "bed occupancy" practices, identifying 88 patients who were not actually hospitalized [2] Group 3: Financial Recovery and Oversight - An expert review group has been formed to conduct quarterly cross-reviews of hospitalization records, resulting in the review of 4,143 cases this year, with 403 cases identified as having inadequate admission criteria, leading to the recovery of over 1.57 million yuan in medical insurance funds [2] - The article emphasizes the importance of medical insurance funds as critical financial resources for insured individuals, highlighting ongoing efforts to strengthen oversight and enhance the effectiveness of governance in the healthcare sector [2]

21世纪经济报道记者韩利明 国家医保局官微近日披露，中国裁判文书网公开的一份刑事判决书显示，某医药公司医药代表陆某为提 升个人销售业绩，篡改三名患者基因检测报告，致使不符合用药条件的患者使用肿瘤靶向药并报销医 保，造成医保基金损失。 判决书载明，陆某主要负责推广肺癌靶向药甲磺酸奥希替尼片，该药获批可用于经检测确认存在 EGFRT790M突变阳性的局部晚期或转移性非小细胞肺癌成人患者。但为完成销售指标，陆某在明知患 者EGFRT790M基因突变检测结果均为阴性、不符合用药条件的情况下，使用软件将患者报告中的"阴 性"结果篡改至"阳性"。 凭借虚假的阳性检测报告，患者在医院违规获得医保报销的奥希替尼，合计造成国家医保基金损失 27540元。经法院审理，最终判决陆某犯诈骗罪，判处有期徒刑八个月，并处罚金人民币七千元；退赔 在案的违法所得予以发还。 医保基金作为参保人的"救命钱"，对解决"看病贵、看病难"问题至关重要。然而，庞大的基金体量也让 部分利益相关方受利驱动铤而走险，骗保行为时有发生。从近年监管实践看，我国对医保骗保的打击已 日趋常态化、制度化，如何进一步筑牢基金安全防线，成为社会关注的关键。 乱象频现 事实 ...

Group 1 - The article highlights the convenience and benefits of the new insurance service for newborns, allowing parents to settle medical expenses easily through their health insurance cards [1] - The establishment of "newborn insurance service stations" in medical institutions aims to ensure that every newborn is insured, promoting timely enrollment for parents [1] - The city's health insurance fund management has been improved through a special rectification campaign, focusing on safeguarding public funds and enhancing service efficiency [1] Group 2 - The article discusses the issues of fraud and misuse of health insurance funds, emphasizing the need for stricter regulation and oversight in the sector [2] - A series of self-inspections and corrections have been initiated, resulting in the identification of 109 issues and the referral of 76 suspicious cases [2] - Collaborative mechanisms among various departments have been established to address key issues in health insurance fund management [2] Group 3 - The article reports on the disciplinary actions taken against 143 individuals involved in violations related to health insurance funds, with 16 individuals detained [3] - A specific case of embezzlement involving nearly 2 million yuan has been highlighted, showcasing the effectiveness of the ongoing rectification efforts [3] - Recommendations for improving internal regulations and closing loopholes have been issued to prevent future misconduct [3] Group 4 - The implementation of a big data monitoring platform aims to enhance the oversight of health insurance fund operations, allowing for quick identification and response to anomalies [4] - The platform has been effective in detecting unusual prescription patterns and facilitating comprehensive inspections [4] - The transition from manual checks to intelligent monitoring is being pursued to improve efficiency and accountability in fund management [4] Group 5 - The article mentions a reduction in medical service fees for various tests, resulting in significant savings for patients [5] - The initiative to lower prices for medical services is part of a broader "benefit action" aimed at making healthcare more affordable [5] - Overall, the reduction in testing fees has led to a decrease of 213 million yuan compared to the previous year [5]

Group 1 - The core viewpoint emphasizes the importance of encouraging the development of innovative drugs to enhance clinical medication technology and improve public health, while also supporting the self-reliance and technological innovation of the biopharmaceutical industry [1] - The provincial medical insurance bureau and health committee have jointly issued a notice to support high-quality development of innovative drugs across the entire chain, aiming to better meet the public's needs for disease prevention, treatment, and medication [1] - The notice outlines measures to support the inclusion of innovative drugs in the basic medical insurance drug list and to establish a dynamic adjustment mechanism for this list based on the capacity of the insurance fund and clinical advancements [1] Group 2 - Local medical insurance and health departments are required to focus on key issues and develop targeted measures to ensure effective implementation of policies, including evaluating the impact of support measures [2] - There is an emphasis on improving data sharing and monitoring related to drug usage among relevant departments to provide data support for dynamically improving policies that support innovative drug development [2] - To strengthen fund supervision, local areas are encouraged to innovate regulatory methods, enhance big data analysis, and integrate online and offline inspections to combat fraud in medical insurance [2]

Core Viewpoint - The article highlights the increasing regulatory measures by the National Medical Insurance Administration to combat fraudulent practices in medical insurance, particularly focusing on retail pharmacies involved in scams such as drug swapping and false prescriptions [4][6][10]. Regulatory Actions and Cases - The National Medical Insurance Administration has initiated a special rectification campaign from now until December 31, 2025, targeting illegal activities such as selling back medical insurance drugs and fraudulent claims for maternity benefits [6][8]. - A case in Sanya, Hainan Province, revealed a network of pharmacies colluding with intermediaries to exploit insurance funds, resulting in over 3.3 million yuan in fraudulent transactions [8]. - In contrast, a case in Ganzhou, Jiangxi Province, exposed smaller-scale, routine fraud involving the forgery of prescriptions, amounting to 27,711.63 yuan, highlighting the pervasive issue of regulatory non-compliance at the grassroots level [9]. Technological and Systematic Improvements - The implementation of a scoring system for key personnel in pharmacies has been established, where accumulating 12 points leads to the termination of medical insurance payment qualifications for individuals involved in fraud [11]. - The use of advanced technologies such as big data, traceability codes, and real-time monitoring is enhancing the precision and effectiveness of medical insurance fund supervision [11][16]. Achievements and Future Plans - Various regions have reported significant recoveries of misappropriated medical insurance funds through rigorous inspections and self-audits, with Hunan Province recovering 1.95 million yuan from 100 medical institutions [14]. - The article notes that the regulatory framework is evolving towards a more comprehensive and multi-dimensional approach, with a focus on preemptive measures rather than solely punitive actions [13][16]. - Future plans for the "14th Five-Year Plan" period emphasize the need for innovative regulatory methods and enhanced monitoring to safeguard medical insurance funds, particularly in regions with unique challenges [15][16].

Core Viewpoint - The recent decision by Xinxiang, Henan to limit outpatient daily payment amounts for medical insurance has sparked significant public attention, but the policy was quickly revoked, highlighting the challenges in managing outpatient insurance funds effectively [3][4]. Group 1: Outpatient Insurance Fund Management - Xinxiang's initial policy aimed to reduce fraudulent expenditures from the medical insurance fund by imposing daily limits on outpatient claims, which was seen as a crude attempt at fund management [4]. - The rapid increase in outpatient visits, totaling 57.49 billion in 2024 compared to 48.7 billion in 2023, indicates a growing challenge for insurance fund oversight, as the number of claims outpaces the ability to monitor them effectively [6]. - The primary difficulties in managing outpatient insurance funds include the vast number of outpatient visits across numerous healthcare facilities and the inadequacy of current monitoring technologies to detect fraudulent activities [6][12]. Group 2: Regulatory Challenges and Responses - The regulatory environment is complicated by the high volume of outpatient claims and the diverse nature of treatments, such as traditional Chinese medicine, which complicates the establishment of effective oversight standards [6]. - Many regions have reported issues with fraudulent practices, including the manipulation of treatment codes and the substitution of non-insured medications for insured ones, making traditional regulatory methods insufficient [6][7]. - Recent announcements from various local medical insurance bureaus have prohibited year-end "spending sprees" where insured individuals rush to use their benefits, which can lead to unnecessary expenditures and strain on the insurance fund [10][11]. Group 3: Recommendations for Improvement - Experts suggest that improving the management of outpatient insurance funds requires advancements in intelligent regulatory systems, increased electronic medical record usage, and enhanced collaboration among regulatory bodies [12]. - There is a need for greater public awareness regarding the responsible use of medical insurance, as many insured individuals still perceive it as a welfare benefit rather than a shared responsibility [11].

Core Viewpoint - The recent decision by Xinxiang, Henan to impose daily payment limits on outpatient services has sparked public concern, but the local health insurance bureau has announced the cancellation of these limits effective November 12, 2025, highlighting the challenges in outpatient fund regulation [1][2]. Group 1: Outpatient Fund Regulation Challenges - The rapid increase in outpatient visits, totaling 57.49 billion in 2024 compared to 48.7 billion in 2023, poses significant regulatory challenges for health insurance funds [2][3]. - The primary difficulty in outpatient fund regulation is the vast number of outpatient visits across numerous healthcare facilities, making comprehensive oversight impractical [2][3]. - The lack of effective regulatory standards for specific treatment projects, such as traditional Chinese medicine, creates opportunities for fund misuse [2][3]. Group 2: Fraudulent Practices and Regulatory Responses - Innovative and covert fraudulent practices, such as altering treatment codes and substituting non-insured drugs for insured ones, complicate timely detection by traditional regulatory methods [3][4]. - The annual payment limits for outpatient services are relatively low for residents, while the limits for employees can reach thousands, making employee outpatient services more susceptible to fraud [3][4]. - Local health insurance bureaus have issued warnings against end-of-year spending sprees, where some healthcare providers may exploit the misconception that unused insurance funds will expire [4][5]. Group 3: Recommendations for Improvement - Research indicates that the current outpatient fund regulation faces challenges such as underdeveloped intelligent oversight systems, low electronic medical record usage, and insufficient collaboration among regulatory bodies [7]. - Recommendations include advancing intelligent regulatory systems, enhancing the electronic documentation of outpatient visits, and improving the professional capacity of regulatory personnel [7].

Group 1 - The core viewpoint emphasizes the importance of the Guangxi Zhuang Autonomous Region's Wuzhou City Discipline Inspection Commission and Supervisory Commission in managing issues related to medical insurance fund management as a key focus for enhancing supervision in the public welfare sector [1] - The establishment of a collaborative mechanism between the Discipline Inspection Commission and the municipal medical insurance department aims to ensure the safe and standardized operation of medical insurance funds, thereby protecting the health rights of the public [1] - Regular meetings and a communication coordination mechanism have been established to report on progress and address challenges, enhancing information sharing and the transfer of leads among departments [1] Group 2 - The Discipline Inspection Commission has initiated self-examination and correction actions regarding illegal use of medical insurance funds, identifying and rectifying prominent issues while urging the recovery of misused funds [1] - A collaborative action framework involving the Discipline Inspection Commission, medical insurance, and multiple departments has been formed to focus on key targets and issues related to medical insurance fund management [1] - The analysis of systemic and deep-rooted issues has led to the issuance of over 74 recommendations and suggestions aimed at improving the management of medical insurance contributions and the use of funds by designated medical institutions [2]