经查，该康复医院工作人员将参保人员录入住院系统后，未及时将其从民政系统中退出，导致数据重 叠，由于发现及时，未造成民政养老待遇重复支付。 医保基金监管涉及面广、主体多元、资金量大，传统监管方式难以精准识别"跑冒滴漏"问题。为此，市 纪委监委推动市医疗保障局充分运用大数据手段，依托省级智慧医保监管平台，构建多维度分析模型， 对"超频次、超长期住院""共同住院"等重要风险点实行动态监测，有效提升监管精准度。 "参保人员吴某某在某康复医院使用医保住院治疗期间，其在民政系统的登记状态仍为养老院在院状 态，请立即核查。"近日，大数据分析模型发出预警，提示该康复医院可能存在"医养合谋"骗保问题。 我们随即督促市医疗保障局启动联合执法机制，会同卫健、民政等部门开展现场核查。 联合执法人员责令该院健全完善院内管理制度，加强工作人员业务培训，并对全市康养机构"挂床住 院"等违规行为开展多轮日巡夜检，查实无故不在院病人88人。 此外，市医疗保障局组建专家评审组，每季度开展住院病历交叉评审，重点审核入院指征、临床用药、 诊疗合理性及康复项目适配度等内容。今年以来，共审核住院病历4143份，查实入院指征把关不严病历 403份，追回医 ...

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]

Core Points - The article highlights the misuse of medical insurance cards for purchasing non-medical products, such as ordinary toothbrushes and face masks, which have been falsely classified as medical devices to exploit insurance benefits [1][2] - There is a growing concern regarding the deceptive practices by companies and pharmacies that mislabel everyday items as medical equipment, leading to significant financial losses for the medical insurance fund [1][2] Summary by Sections Medical Device Misclassification - Ordinary toothbrushes have been reclassified as "dental brushes," and face masks as "medical dressings" to enable insurance reimbursement [1] - This practice has been ongoing, with various products being sold under the guise of medical devices, despite their actual non-medical use [1] Regulatory Challenges - The article discusses the challenges in regulating these practices, as consumers are often misled by the medical device labeling [2] - It emphasizes the need for stricter enforcement of medical device certification and improved oversight by regulatory bodies [2] Recommendations for Improvement - To combat the misuse of medical insurance cards, the article suggests enhancing consumer education about insurance policies and encouraging active participation in monitoring [2] - It calls for a robust regulatory framework that includes immediate action against identified violations to deter further misuse [2]

Core Insights - The Shaanxi Provincial Health and Wellness System held a warning education conference to address the misuse of medical insurance funds in township health centers, reporting typical cases of violations [1] - The provincial disciplinary inspection and supervision authorities are focusing on the management of medical insurance funds, collaborating with multiple departments to combat corruption and ensure compliance [1][2] - A big data supervision model has been established to enhance monitoring precision, allowing for real-time detection of suspicious activities related to medical insurance fund usage [2][3] Group 1 - The conference highlighted the discovery of improper medical expenses being included in insurance fund settlements, leading to the recovery of over 790,000 yuan in misused funds [1] - Six individuals received administrative penalties, and 16 doctors were disciplined for their involvement in the violations [1] - The provincial authorities are implementing a focused approach to tackle fraud and ensure compliant payments through 15 specific work objectives [1] Group 2 - The collaboration between the disciplinary inspection and medical insurance departments has led to the identification of over 7,000 suspicious cases related to drug traceability codes, resulting in the discovery of more than 700 violations [2] - A mechanism combining big data screening, cross-checking, and targeted investigations is being utilized to monitor medical institutions and their billing practices [2] - The Yaozhou District has initiated a comprehensive investigation of medical institutions to pinpoint issues in fund usage [2] Group 3 - The Huayin City disciplinary inspection committee is urging the medical insurance bureau to establish a risk prevention system while expanding coverage, utilizing intelligent auditing systems for dynamic monitoring [3] - A dual approach of online monitoring and offline supervision is being employed to enhance the effectiveness of fund management [3] - The provincial authorities have publicly exposed five cases of fraud, reinforcing the deterrent effect of their actions [3] Group 4 - The provincial disciplinary inspection committee plans to continue deepening the rectification actions in the medical field, aiming to strengthen the regulatory framework for medical insurance funds [4]