（原标题：医药代表篡改基因检测报告骗取医保被判刑） 经济观察网 近期，中国裁判文书网公开了一份刑事判决书，某医药公司医药代表，为追逐个人销售业 绩，篡改患者基因检测报告，给不符合用药条件的患者使用肿瘤靶向药，造成医保基金损失，最终以诈 骗罪获刑。 被告人陆某，某医药公司医药代表，主要负责推广肺癌靶向药甲磺酸奥希替尼片（下称"奥希替尼"）。 奥希替尼获批可用于治疗经检验确认存在EGFRT790M突变阳性的局部晚期或转移性非小细胞肺癌成人 患者。2020年10月至2021年4月期间，陆某为完成销售指标，明知患者徐某、赵某、宋某EGFRT790M基 因突变检测结果为阴性，不符合奥希替尼的使用条件，仍擅自使用办公软件将三名患者的检测报告中基 因突变"阴性"结果修改为"阳性"。后由某医院呼吸内科医师陆某于2020年10月，依照虚假阳性报告为患 者徐某使用医保报销开具奥希替尼1盒；某医院呼吸内科医师尹某于2021年3月、4月，依照虚假阳性报 告为患者赵某使用医保报销开具奥希替尼2盒；由某医院呼吸内科医师胡某于2021年1月至4月，依照虚 假阳性报告为患者宋某使用医保报销开具奥希替尼5盒。合计共造成医保基金损失27540元 ...

Core Points - The Sichuan Provincial Medical Insurance Bureau announced the successful investigation of a major medical insurance fraud case involving five medical institutions, including Chengdu Jiuxing Kidney Hospital and Chengdu Gaoxin Bolin Hospital, with a total fraud amount of 48.08 million yuan [1] - The investigation led to the termination of medical insurance agreements with the involved institutions, the detention of 35 individuals, and the approval of arrests for 16 individuals [1][4] - Longsheng Medical, a well-known national dialysis chain, operates over 100 hospitals and centers across 15 provinces, providing services to more than 17,000 dialysis patients [2] Medical Institutions Involved - Chengdu Jiuxing Kidney Hospital and Chengdu Gaoxin Bolin Hospital are part of Longsheng Medical, which has been implicated in fraudulent activities such as selling "return flow drugs" and offering free dialysis [1][2] - Following the fraud investigation, Chengdu Jiuxing Kidney Hospital has reportedly ceased operations, while Chengdu Gaoxin Bolin Hospital has been rebranded as Chengdu Gao Xin South Hospital, which is currently operational [4][5] Regulatory Actions - The National Medical Insurance Administration has issued a notice to address fraudulent practices in the dialysis sector, emphasizing the need for medical institutions to charge based on actual services provided and prohibiting misleading practices such as "free treatment" [3] - The Sichuan Provincial Medical Insurance Bureau has recovered 4.89 million yuan in principal and penalties from the involved institutions and has suspended payments totaling 70.41 million yuan [4]

Core Viewpoint - The company Shenzhou Cell is embroiled in a series of medical insurance fraud cases involving its product, Anjain, which is a recombinant human coagulation factor VIII for hemophilia A patients. Investigations are ongoing, and several patients and sales representatives are implicated in fraudulent activities related to insurance claims [1][4][5]. Group 1: Company Overview - Shenzhou Cell's Anjain is the first domestically approved recombinant human coagulation factor VIII in China, launched in 2021, primarily for controlling and preventing bleeding in hemophilia A patients aged 12 and older [2]. - The company claims to adhere to legal and compliance standards, emphasizing that the actions of individual sales representatives do not reflect the overall operational strategy of the company [4][20]. - Following the launch of Anjain, the price of recombinant factor VIII has decreased by nearly 50% due to national drug procurement policies [4]. Group 2: Fraud Allegations - The allegations involve Shenzhou Cell's sales team collaborating with patients to fraudulently obtain insurance reimbursements by misrepresenting medical conditions, leading to significant financial gains from the insurance fund [5][11]. - A specific case highlighted that a patient fraudulently obtained over 1.19 million yuan in reimbursements, with the company allegedly providing a 4% rebate on the medication costs to patients [5][19]. - The legal framework stipulates that adult hemophilia patients are only eligible for insurance reimbursement when they exhibit bleeding symptoms, making the fraudulent claims particularly egregious [8][11]. Group 3: Market Impact - Anjain has rapidly gained market share, becoming the leading product in its category within three years of its launch, attributed to its lower price compared to foreign competitors [16]. - The company has established a charitable assistance program that allows patients to receive treatment at no cost, effectively covering the out-of-pocket expenses through partnerships with charitable organizations [17][20]. - The sales strategy has reportedly enabled patients to receive not only free treatment but also cash rebates, creating a controversial but effective market penetration model [18][19]. Group 4: Legal and Compliance Issues - Legal experts indicate that the sales representatives may face significant legal consequences, as their actions reflect a clear understanding of the fraudulent nature of their activities, despite claims of merely following company directives [15][21]. - The company has publicly stated its commitment to compliance and has denied any involvement in fraudulent activities, asserting that any misconduct by individual employees does not represent the company's practices [4][20].

Core Insights - The Shanghai police have dismantled a healthcare fraud ring involving a designated medical institution, which has committed over 50,000 fraudulent claims amounting to more than 120 million yuan in two years [1][13]. Group 1: Fraud Scheme Details - The fraud was orchestrated by the Yiyang Traditional Chinese Medicine Hospital, where internal staff colluded with external pharmaceutical companies to submit false claims [3][9]. - Investigations revealed that many insured individuals did not actually visit the hospital, yet their records showed multiple prescriptions and treatments [3][9]. - A specific employee, Zhao, was noted for bringing numerous neighbors to the hospital, resulting in over 300 visits in just six months [5]. Group 2: Investigation Findings - The police found that during visits, patients were not properly examined; instead, they were simply asked to sign and pay without any consultation [7]. - Data comparisons indicated that while only 2 to 3 patients were present, records showed over 10 visits, indicating a systematic fraud operation [9]. - Some staff members were involved in swapping expensive herbal medicines for cheaper alternatives, further complicating the fraud [11]. Group 3: Legal Actions and Outcomes - Following the identification of the fraud ring's structure, a major operation in October led to the arrest of 34 suspects, with additional arrests of 56 insured individuals in April [13]. - The fraud ring was led by a figure named Yan, who coordinated with stakeholders from the involved medical institutions to execute the fraudulent activities [13].

Group 1 - The article highlights the serious issue of healthcare fraud in Shanghai, particularly involving illegal resale of medications acquired through the medical insurance system [1][2] - In 2025, Shanghai authorities dismantled seven healthcare fraud rings, arresting over 130 suspects and involving more than 14 million yuan in fraudulent activities [2] - A specific case involved a network where medications were purchased at significantly reduced prices (as low as 10 yuan) from insured individuals and then resold at higher prices, creating a comprehensive illegal supply chain [3][4] Group 2 - The fraud operations often targeted elderly individuals, with perpetrators posing as second-hand goods collectors to encourage them to sell their prescribed medications [6][8] - Two private Chinese medicine clinics were found to have engaged in fraudulent practices, including excessive billing for services not rendered and manipulation of medication records [10][11] - A significant fraud ring led by a figure named Yan was uncovered, with over 50,000 fraudulent claims amounting to more than 12 million yuan in total [12]

Core Viewpoint - The article highlights the serious issue of healthcare fraud in Shanghai, particularly focusing on two private traditional Chinese medicine clinics that have defrauded the medical insurance system of over 12 million yuan through false diagnoses and treatments [3][4]. Group 1: Fraudulent Activities - A police investigation revealed that the Shanghai Yiyang Traditional Chinese Medicine Hospital had suspicious billing practices, with many patients showing frequent visits without actual treatment, indicating potential fraudulent activities [3][4]. - The investigation uncovered that staff members at the clinics were involved in swapping expensive medicinal herbs for cheaper alternatives, profiting from the difference while defrauding the insurance system [4]. Group 2: Criminal Organization Structure - The criminal organization involved clinic management and staff who coerced employees into conducting false diagnoses, while also collaborating with "scalpers" to bring in insured patients for fraudulent billing [4]. - The operation included a network of individuals who collected and resold medications illegally, creating a comprehensive illicit supply chain [8]. Group 3: Law Enforcement Actions - The police successfully dismantled a fraud ring, arresting 12 suspects and seizing over 1.2 million yuan worth of drugs [7][11]. - New regulations were introduced requiring pharmacies to scan drug traceability codes during sales to combat fraud, with penalties for non-compliance [12][13].