今年7月25日，四川省医保局官网发文，成功侦破"5·20"特大医保诈骗案，查实成都九星肾病医院、成 都高新博力医院等5家医疗机构、相关职业骗保人存在倒卖"回流药"、免费透析等欺诈骗保行为，涉案 金额4808.47万元。截至目前，成都市医保局已全部解除5家涉案机构医保协议，公安机构刑拘35人，检 察院批准逮捕16人，移送起诉14人。 血液透析是尿毒症患者肾脏替代治疗方式之一。尿毒症患者一般需要每周2—3次定期到血液透析机构进 行血液透析。尿毒症患者一般需要长期甚至终身治疗，一般会固定在一家机构进行血液透析。为争夺患 者资源，部分血液透析机构通过免费血液透析、车接车送、包吃包住甚至发放补贴等方式拉拢尿毒症患 者。然而免费血液透析背后，部分机构被发现存在涉嫌骗保的问题。 针对血液透析领域涉嫌骗保的问题，今年4月，本报进行过报道（见《"免费"血液透析幕后》）。 据了解，针对血液透析领域及其他领域存在涉嫌骗保的问题，国家医保局发布了《关于将一次性高值医 用耗材重复使用、拉拢人员开展血液透析以及医用胶片违规收费纳入专项整治工作的通知》（以下简 称"《通知》"）。 《通知》要求，开展血液透析项目的医疗机构应当按照为患者实际 ...

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].