在清算方面,个人账户跨省共济产生的费用按月全额清算,参照跨省异地就医清算流程,由国家统一清分、 省市分级清算,可依托预付金保障清算时效,资金规模动态调整。 在共济额度内,共济人不能再使用该额度的个人账户资金,也就是说,相应额度的资金在个人账户中"被冻 结"。共济关系解除后,未使用额度将返还共济人的账户,共济人可以继续使用相应额度的资金。 依托全国统一的医保信息平台设立个人医保钱包,共济人通过医保钱包为被共济人设定共济额度。个人 医保钱包实行虚拟额度管理,医保基金不得实际拨入个人医保钱包,保障医保基金安全。 ...

不久前，外市一家医保定点药店涉及药品追溯码的违规问题被曝光。该药店负责人通过非法渠道获取了 大量已售出药品的追溯码信息，并利用这些"旧码"伪造销售记录。在实际并未购入和销售相应药品的情 况下，系统内却显示这些"高端药品"已被合规售出，并以此向医保基金申请报销。这就好比将已经"注 销"的身份证反复使用，凭空捏造出根本不存在的交易，恶意套取宝贵的医保资金。 这种行为危害巨大。它直接盗取了本应用于民众看病的"救命钱"，破坏了医保支付的精准性与公平性。 更令人担忧的是，若假药、劣药凭借伪造的追溯码流入医保体系，将对患者的健康构成直接威胁。 为了斩断伸向追溯码的黑手，筱智注意到医保和市场监管部门迅速行动。一方面，监管部门升级了追溯 码系统，强化加密与验真技术，使"一码多用"和伪造变得极其困难。另一方面，加强了数据监控与实地 稽核的联动，当系统发现某批次追溯码报销频率异常时，执法人员便能快速锁定目标，进行现场核查。 守护医保基金安全，科技是盾牌，但每个人的意识才是基石。作为参保人，我们应养成核对药盒追溯 码、查询购买记录的习惯，对异常现象保持警惕并积极举报。药店和医疗机构更应恪守诚信，严守规 范。 点击收听： 那就让我们 ...

一些不法分子给口罩、面膜、防晒衣、化妆品等日常生活用品，换换名字，改改包装，穿上一件"医用"的马甲，就摇身一变成了具有"械字号"认证 的"医疗器械"，摆上了药店的货架，开始蚕食医保个人账户资金。 牙刷叫"牙科用毛刷"，面膜是"医用敷贴"，防晒口罩成"医用隔离垫"……日常生活用品换一件马甲，就堂而皇之进入药店，成了用医保卡结算的"医 疗器械"。"医保卡购物"新变种，正在侵蚀医保个人账户资金，威胁你我共同的"救命钱"。 医保基金是老百姓的"看病钱"，容不得任何人打歪主意。一些人千方百计钻制度的空子，想方设法掏空医保个人账户资金，损害的是每个人的切身利 益。 医保个人账户资金是老百姓健康的"压箱底"钱，不到治病救人的关键时刻，不能随意取用。可惜这笔"救命钱"总是被人盯上，频频伸来"黑手"。 过去，某些药店除了售卖药品，还出售锅碗瓢盆、油盐酱醋，活脱脱是个杂货铺。店员毫不掩饰地诱导消费者用医保卡购买日杂用品，甚至还额外收 取手续费。 在规范治理压力下，如此明目张胆套刷医保卡的行为，近年来大为收敛，但是"医保卡购物"又频频出现新的变种。 本该守住自己医保卡的一些持卡人员，轻信"薅羊毛攻略"，随意刷医保卡购买这些"医疗用 ...

人民财讯12月13日电，2025年12月13日，全国医疗保障工作会议在北京召开。会议要求，要加强医保基 金运行管理，守牢医保基金安全底线。持续加大飞行检查力度，实现全国所有统筹地区及各类基金使用 主体全覆盖，对患者自费率畸高且排名全国前列的统筹地区和定点医疗机构开展"点穴式"飞行检查，坚 决维护人民群众健康权益。坚决支持定点医疗机构根据诊疗需要对必需的医保目录内药品应配尽配。对 倒卖"回流药"等违法违规使用医保基金行为零容忍，坚决从严处罚。 ...

随着互联网医疗、线上购药等新医疗模式不断普及，接下来还可能出现新的药品非法回流方式。比 如，药贩子利用线上平台的虚拟性，通过虚假账号、虚假订单等方式，骗取医保报销后将药品回流市 场。或者利用大数据分析，精准定位有药品出售需求的患者，实施更加精准的诱导和收购。随着医保跨 区域结算等政策的推进，药品的流通范围更广，不法分子还可能会利用区域间监管的差异和信息的不对 称，进行跨区域的药品非法回流活动。这些潜在的非法回流形式，对监管提出了更高要求。 "回流药"花样翻新，治理也要顺势应变。比如，针对日益增多的跨区域倒药行为，多地医保、公 安、市场监管等部门应建立信息共享、联合执法等机制，打破信息壁垒，实现从源头到终端的全链条监 管。针对利用互联网虚拟身份倒药行为，则要借助大数据、人工智能等技术，对医保报销数据、药品流 通数据等进行实时监测和分析，及时发现异常情况，提升精准度等。 近年来，一些人发现倒卖医保药品有利可图，以"医保取现""高价回收"等手段诱导参保人通过医保 报销渠道获取药品，再非法转手销售流入市场。这类医保"回流药"给用药人带来了直接的健康风险，并 严重侵害了国家医保基金的安全。媒体近日深入调查发现，医保"回 ...

Core Viewpoint - The National Medical Insurance Administration emphasizes the importance of safeguarding the medical insurance fund and has released five typical cases of individual fraud to strengthen legal awareness and deter fraudulent activities [1] Group 1: Case Summaries - Case 1: In Qinhuangdao, Hebei, an individual named Guan and four accomplices collected over 70 social security cards to fraudulently obtain 120,000 yuan in reimbursements for a drug, which they then sold in other provinces [2] - Case 2: In Wuhu, Anhui, an individual named Xiao exploited his medical condition to obtain excess medication, selling the surplus for a total fraud of 51,950.91 yuan [3] - Case 3: In Zhengzhou, Henan, Zhang falsified injury details to claim 39,477.26 yuan in reimbursements after already receiving compensation from his employer for a work-related injury [4] - Case 4: In Yantai, Shandong, Wang and two accomplices misrepresented a work-related injury as a home accident, resulting in a fraudulent claim of 18,070.63 yuan [5][6] - Case 5: In Benxi, Liaoning, Liu misrepresented a traffic accident to claim 6,549.11 yuan from the medical insurance fund, which was ultimately recovered [7] Group 2: Fraud Patterns and Consequences - The five cases illustrate two main types of fraud: selling medical drugs and falsifying documentation to claim reimbursements [8] - All individuals involved faced criminal penalties and were required to fully repay the defrauded medical insurance funds, highlighting the serious legal repercussions of such actions [8] - The National Medical Insurance Administration warns the public against engaging in fraudulent activities, stressing the importance of adhering to medical insurance laws and protecting personal rights [8]

Core Insights - China Life Property & Casualty Insurance's Yichun Branch is committed to enhancing its non-auto insurance services, particularly in the area of major illness insurance for rural residents in Shanggao County [1][3] - The company aims to fulfill its political and social responsibilities as a central state-owned enterprise by optimizing operational management and improving service quality [1][3] Group 1 - The company provided a detailed report on its services related to the major illness insurance project for rural residents, emphasizing its role in underwriting, claims processing, and safeguarding the medical insurance fund [1] - The leadership of Shanggao County's Medical Security Bureau acknowledged the professional services and achievements of the company in the major illness insurance sector [3] - Both parties discussed strategies to strengthen cooperation and enhance multi-level insurance services to protect the medical insurance fund and promote high-quality development of local medical security [3] Group 2 - The company plans to actively leverage its insurance capabilities to meet the diverse health protection needs of the local community, thereby enhancing the public's sense of gain, security, and happiness [3]

Core Points - The article highlights the issue of "yin-yang pricing" in designated pharmacies, where the same cold medicine is priced differently for insured and uninsured customers, leading to significant price discrepancies [1] - It emphasizes the need for strict regulation and monitoring of pharmacies engaging in such practices to protect the integrity of the medical insurance fund and public trust in the healthcare system [1][2] Group 1 - The practice of "yin-yang pricing" is driven by pharmacies attempting to alleviate operational pressures by shifting costs onto insured patients, alongside a lack of transparency in drug pricing [1] - A recent notification has been issued to enhance monitoring and handling of "yin-yang pricing" in designated retail pharmacies, calling for serious investigations and penalties [1] - Measures against pharmacies practicing "yin-yang pricing" may include interviews, suspension of medical insurance settlements, and termination of medical service agreements, aiming to deter such illegal activities [1] Group 2 - To combat the "yin-yang pricing" phenomenon, there is a call for preventive measures, including the use of technology to create a comprehensive supervision network through drug price comparison apps and traceability codes [2] - The article stresses that the qualification for medical insurance designated pharmacies should not be seen as a license for unregulated practices but as a commitment to honest business operations [2] - The goal is to ensure fair and transparent drug purchasing, allowing the medical insurance fund to be utilized effectively, thereby increasing public confidence in the healthcare system [2]

Core Points - The report highlights a case of fraudulent billing practices at the Eye Hospital in Xiangshan, where a doctor received a reward for reporting the hospital's illegal switching of medical insurance billing items [1] - The hospital was found to have engaged in fraudulent activities that resulted in a loss of 27,826.70 yuan to the medical insurance fund [1] - The hospital has faced multiple penalties for various violations, totaling 131,500 yuan in fines this year [3][4] Group 1: Fraudulent Activities - The Xiangshan Eye Hospital was reported for switching a non-covered medical procedure (meibomian gland examination) to a covered procedure (corneal topography examination) to receive insurance payments [1] - The hospital's fraudulent billing practices were confirmed to have occurred between November 2023 and May 2025, involving a total of 45,100 yuan in improper charges [1] - The hospital was fined 44,522.72 yuan by the Xiangshan Medical Security Bureau for its fraudulent activities [4] Group 2: Regulatory Actions - The Xiangshan Eye Hospital has received two administrative penalties this year, with a total fine amount of 131,500 yuan [3] - The Xiangshan Health and Wellness Bureau issued a warning and fined the hospital 87,000 yuan for employing unqualified personnel in prescription dispensing [3] - The hospital's actions have prompted ongoing scrutiny and reporting from medical professionals, aiming to ensure compliance with regulations and protect the integrity of the medical insurance fund [1]

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].