中国经济网北京9月25日讯 甘肃日报报业集团下属奔流新闻近期报道《爱尔眼科医院串换医保收费项目 医生投诉获2000元奖励》显示，9月12日，奔 流新闻记者从武汉市中心医院急诊科主任艾芬处获悉，她因投诉浙江象山爱尔眼科医院串换医保收费项目，获得象山县医疗保障局奖励2000元。 《象山县医疗保障局投诉举报奖励通知书》显示，该局于2025年5月19日受理艾芬投诉象山爱尔眼科医院串换医保收费项目的举报信。经查，在2023 年11月至2025年5月期间，该医院开设"目录外项目睑板腺检查串换成医保目录内项目角膜地形图检查收费"并纳入医保基金支付，存在串换项目收费的违法 行为，涉及违规费用45100元，造成医疗保障基金损失27826.70元，属实。根据浙江省相关办法，决定给予2000元人民币奖励。 南方都市报报道《象山爱尔眼科因骗保行为被罚逾13万元，举报人获奖励两千》显示，艾芬表示，近年来她已多次就多地爱尔眼科医院存在的违法违 规执业问题向有关部门进行反映，此次为第二次获得举报奖励。她强调，举报目的在于推动医疗机构规范运营，维护医保基金安全，奖励金额并非关注重 点。 象山县卫生健康局8月12日因象山爱尔眼科医院有限公司使 ...

Core Viewpoint - The National Healthcare Security Administration (NHSA) is intensifying efforts to combat healthcare fraud, emphasizing the importance of safeguarding the medical insurance fund, which is crucial for public welfare and the sustainability of the healthcare system [1][8]. Summary by Cases Case 1: Shenzhen Fraud - A resident in Shenzhen, identified as Li, exploited others' medical insurance accounts to sell drugs illegally, defrauding the healthcare fund of 93,013.68 yuan. The accomplice, Wang, purchased these drugs for 169,025.00 yuan. Both were criminally detained, and Li was sentenced to 2 years and 4 months in prison [1]. Case 2: Beijing Drug Trafficking - A couple in Beijing, Yu and Wang, were caught selling healthcare drugs at a lower price after acquiring them from elderly individuals. The total value of the drugs involved exceeded 110,000 yuan. They received sentences of 1 year and 2 months, with a suspended sentence and a fine of 20,000 yuan [2]. Case 3: Hubei Abuse of Benefits - In Hubei, two individuals, Qiu and Ke, misused their outpatient chronic disease benefits to sell drugs, resulting in a total fraud amount of 408,25.78 yuan. Qiu was sentenced to 3 years and 9 months, while Ke received a 2-year sentence [3]. Case 4: Shanghai Resale of Drugs - A 74-year-old retiree in Shanghai, identified as Hu, was found reselling drugs purchased through the healthcare system. The NHSA recovered 5,223.31 yuan in funds and imposed a fine of 13,320.00 yuan [4]. Case 5: Xinjiang False Claims - A retiree in Xinjiang, identified as Tan, submitted fraudulent medical bills over 27 instances, defrauding the healthcare fund of 426,218.45 yuan. He was sentenced to 3 years in prison with a 4-year suspension and fined 50,000 yuan [5]. Case 6: Jilin Duplicate Claims - In Jilin, an individual named Gao attempted to claim reimbursement for medical expenses already covered by a third party, fraudulently obtaining 27,394.69 yuan. The case has been forwarded to law enforcement for further investigation [6]. Case 7: Tianjin Identity Fraud - In Tianjin, Zhang was found using another person's medical insurance card for medical services, defrauding the fund of 11,284.99 yuan. She was ordered to repay the amount and fined 22,569.98 yuan [7]. Regulatory Response - The NHSA is committed to enhancing regulatory measures and utilizing technology to track drug sales, aiming for a zero-tolerance policy against fraud. Citizens are encouraged to report any suspicious activities to protect the integrity of the healthcare fund [8].

Core Viewpoint - The article highlights the increasing challenges in the regulation of medical insurance funds in China, particularly focusing on the rise of fraudulent activities that threaten the integrity of these funds. It emphasizes the judicial system's commitment to combating medical insurance fraud through stringent legal actions and the exposure of various fraudulent schemes [6][10][12]. Group 1: Medical Insurance Fraud Cases - In 2024, a total of 1,156 medical insurance fraud cases were concluded in first-instance trials, resulting in 2,299 individuals being sentenced, marking a year-on-year increase of 131.2%. The total amount recovered from these cases was over 402 million yuan [6][9]. - A specific case involved a hospital in Shanxi, where fraudulent activities led to the inflation of medical expenses by over 9.7 million yuan, with 7 million yuan successfully defrauded from the insurance fund [8][9]. - Another case highlighted involved a medical institution where the operator attracted elderly patients under false pretenses, leading to fraudulent claims amounting to over 3.9 million yuan [9][10]. Group 2: Legal Consequences and Enforcement - The judicial system has adopted a zero-tolerance approach towards medical insurance fraud, with severe penalties imposed on offenders, including prison sentences exceeding ten years for major perpetrators [9][12]. - The article outlines the legal repercussions for individuals involved in the illegal sale of drugs obtained through fraudulent insurance claims, emphasizing that such actions can lead to significant penalties, including imprisonment and fines [12][13]. - The Supreme People's Court has indicated that it will continue to strengthen the crackdown on medical insurance fraud, ensuring that offenders are held accountable and that the integrity of the medical insurance fund is preserved [15]. Group 3: Characteristics of Medical Insurance Fraud - Medical insurance fraud is characterized by concentrated crime types, with over 90% of cases involving fraud-related charges. The perpetrators include a diverse range of individuals, from medical institutions to insured individuals and organized fraud groups [14]. - The methods of committing fraud are increasingly sophisticated, with professional fraudsters employing various tactics such as falsifying documents and manipulating medical services to exploit the system [14]. - The scale of fraud is significant, with some cases involving substantial amounts of money, leading to severe damage to the medical insurance system and public trust [14].

Core Viewpoint - The implementation of an intelligent monitoring and auditing system at Shishi City Hospital aims to enhance the safety and efficiency of medical insurance fund management, ensuring that every investment meets the real needs of patients [1]. Group 1: Patient Care Process Monitoring - The system provides real-time alerts during the prescription process to prevent inappropriate medication and misuse of medical supplies, triggering over 210,000 alerts to correct potential violations before they occur [2]. - Daily data screening during patient hospitalization identifies issues such as excessive testing and duplicate charges, allowing for timely corrections by medical staff [2]. - Post-discharge, the system enables comprehensive audits of medical insurance data to identify any overlooked discrepancies by doctors [2]. Group 2: Continuous System Optimization - The system has adapted to 21 key areas of medical insurance regulation, addressing various violations such as duplicate charges and unauthorized use of non-insured materials, generating over 280,000 alerts [3]. - Ongoing updates to the system are designed to meet real-world needs and align with new policy regulations, enhancing hospital oversight and minimizing unnecessary patient expenses [3]. Group 3: Multi-Dimensional Analysis for Service Standardization - The system analyzes violations across departments and physicians, providing detailed insights into the frequency and financial impact of each violation, which aids in targeted training and corrective measures [4]. - Key metrics such as total medical insurance costs and settlement figures are dynamically tracked to ensure expenses remain within reasonable limits [4]. - The hospital is committed to continuously optimizing the intelligent monitoring system to enhance regulatory precision and efficiency in oversight [4].

Group 1 - The core viewpoint emphasizes the importance of safeguarding the medical insurance fund, which is crucial for public health, and highlights the severe penalties imposed on medical insurance fraud cases by the Supreme People's Court [1][2] - In 2024, a total of 1,156 medical insurance fraud cases involving 2,299 individuals were concluded in first-instance trials, marking a year-on-year increase of 131.2%, with over 402 million yuan recovered in losses to the medical insurance fund [1] - The article discusses the emergence of new, more covert methods of medical insurance fraud, including the organized illegal trade of "recovered drugs" through social media, which poses significant risks to public health and safety [1] Group 2 - The article calls for enhanced regulatory measures to address the high incidence of medical insurance fraud, indicating that existing oversight mechanisms need to be expanded and updated to cover a broader range of fraudulent activities [2] - It suggests the implementation of advanced regulatory methods, such as artificial intelligence monitoring and big data analysis, to improve the precision and effectiveness of oversight, aiming to prevent losses and ensure the proper use of medical insurance funds [2]

Group 1 - The core viewpoint of the news is the progress and achievements of China's medical insurance reform during the "14th Five-Year Plan" period, emphasizing a people-centered approach and innovation in the healthcare system [1][2] - The basic medical insurance coverage rate remains stable at around 95%, with the number of insured individuals expected to reach 1.327 billion by 2024 [1] - The cumulative balance of the medical insurance fund is projected to be 3.86 trillion yuan by the end of 2024, with a total expenditure of 12.13 trillion yuan during the "14th Five-Year Plan" period, reflecting an annual growth rate of 9.1% [2] Group 2 - The medical insurance system has implemented various measures to enhance fund security, including a comprehensive regulatory framework and the recovery of 104.5 billion yuan in misused funds [2] - As of June 2025, 2.53 million people are enrolled in maternity insurance, with total expenditures reaching 438.3 billion yuan, benefiting over 96 million individuals [2] - The use of smart healthcare services has increased, with over 1.236 billion people using medical insurance codes for direct settlement, and the online service availability rate rising from 55% in 2020 to 92% in 2024 [3]

Group 1 - The Sichuan Province Yibin City Medical Security Bureau held a meeting to address serious violations by the former deputy director of the Medical Insurance Fund Center, highlighting the importance of integrity in public service [1] - An investigation revealed that the former deputy director colluded with private medical institutions to defraud over 3.7 million yuan from the medical insurance fund, leading to his dismissal and criminal prosecution [1] - The Sichuan Provincial Discipline Inspection and Supervision Commission is focusing on issues related to medical insurance fund management, collaborating with multiple departments to combat fraud and corruption [1][2] Group 2 - The Sichuan Province Discipline Inspection and Supervision Commission, along with health departments, has developed a big data monitoring model to dynamically detect anomalies in medical insurance fund usage [2] - Recent alerts from the monitoring platform have led to the discovery of multiple issues, including unusual patient admissions and excessive treatments, prompting further investigations [2] - The commission is prioritizing the investigation of serious cases and has initiated 86 cases related to market regulation and 519 cases concerning drug sales violations [2] Group 3 - The Sichuan Province Discipline Inspection and Supervision Commission is promoting a comprehensive review of business processes and risk points in the medical insurance sector to address vulnerabilities [3] - The Chengdu Discipline Inspection and Supervision Group is encouraging the establishment of a robust regulatory system for medical insurance funds, including cross-checks among local medical institutions [3]

Core Viewpoint - The Supreme People's Court has recently published several typical cases of severe punishment for medical insurance fraud, demonstrating the court's determination to combat such crimes and protect the safety of medical insurance funds and the legitimate rights of the public [1] Group 1: Medical Insurance Fraud Overview - Medical insurance funds are considered the "money for treatment" and "money for life" for the public [1] - In recent years, with the continuous expansion of the medical insurance network and rapid growth of fund scale, the methods of fraud in the medical insurance sector have evolved, including falsifying medical receipts, collusion between patients and doctors to falsely bill for services, and the resale of medications by insured individuals [1] Group 2: Need for Enhanced Regulation - Fraudulent activities have shifted from overt violations to covert data manipulation, necessitating stronger intelligent supervision and inter-departmental collaboration to combat fraud [1] - A system of "intelligent monitoring + departmental collaboration + social governance" should be established, promoting the application of big data anti-fraud models and enhancing random inspections and the connection between administrative and criminal enforcement [1] Group 3: Proposed Measures - Establish a credit scoring system for medical personnel and improve channels for public reporting to create a normalized deterrent effect [1] - These measures aim to effectively safeguard medical insurance funds and protect the legitimate rights of the public in terms of medical security [1]

Core Points - The new regulation mandates that from July 1, 2023, medical institutions must scan drug traceability codes before settling with medical insurance funds, enhancing drug safety [1] - By January 1, 2026, all medical institutions are required to fully collect and upload drug traceability codes, establishing a comprehensive tracking system for pharmaceuticals [1] - The traceability code acts as a unique electronic identity for each drug, ensuring that each box of medication has a single sales record, thus preventing counterfeit and swapped drugs [1] Industry Impact - The integration of drug traceability codes with medical insurance is significant for public drug safety, effectively combating issues like "returned drugs" and fraudulent transactions [2] - The traceability system allows for precise monitoring of high-priced drugs, ensuring they are used appropriately and reach the patients in need [2] - The National Medical Insurance Administration has already demonstrated the effectiveness of this system by investigating the traceability codes of specific drugs, thereby safeguarding both drug safety and insurance funds [2] Public Engagement - Consumers are encouraged to actively participate in ensuring their own drug safety by following six key practices when purchasing medications, including verifying the presence of traceability codes and scanning them for authenticity [3] - The promotion of drug traceability codes is essential, with the goal of making the scanning process a standard practice in every drug transaction [3] - Strengthening regulatory measures around drug traceability codes will help close potential loopholes and enhance public health protection [3]

Core Viewpoint - Guangxi has officially implemented a "no code, no settlement" policy for designated retail pharmacies under the medical insurance system, requiring pharmacies to scan traceability codes for medical insurance drug sales to ensure safety and prevent counterfeit drugs [1][2] Group 1: Implementation Details - All designated retail pharmacies in Guangxi must scan traceability codes and upload information to the medical insurance information platform for drug settlement [1] - The traceability code acts as an "electronic ID" for each drug, assigned from production to sales, allowing for quick identification of counterfeit or substandard drugs [1] - As of now, Guangxi has collected 940 million traceability codes covering 19,000 medical institutions [1] Group 2: Consumer Protection Measures - The "no code, no settlement" policy will not affect the purchasing process for insured individuals or the normal reimbursement of medical insurance [1] - For drugs that have not yet been assigned codes, they can be temporarily included in a "no code library" for real-time data collection and review [1] - Consumers can verify their purchase information through the National Medical Insurance Bureau's official app by scanning the traceability code [2] Group 3: Impact on Drug Safety and Fraud Prevention - The implementation of this policy is expected to effectively curb the influx of counterfeit and "returned" drugs into the market, enhancing public safety [2] - It will also utilize big data analysis to combat various fraudulent activities related to medical insurance funds, ensuring safer and more efficient use of these funds [2]