Core Viewpoint - The article emphasizes the severe nature of medical insurance fraud, which constitutes a significant infringement on public resources and undermines the rational use of medical resources and the legitimate rights of patients [1][2]. Group 1: Medical Insurance Fund Security - The medical insurance fund is crucial for public health and its safety directly impacts the interests of insured individuals and the sustainable development of the medical insurance system [2][4]. - During the "14th Five-Year Plan" period, the national basic medical insurance coverage rate remains stable at around 95%, with nearly 20 billion instances of medical insurance reimbursements expected from 2021 to 2024, marking a 1.6 times increase compared to 2020 [2][3]. - In 2024, the basic medical insurance fund expenditure is projected to reach 2.98 trillion yuan, with a 5% decrease in personal patient burdens year-on-year [2][3]. Group 2: Characteristics of Fraudulent Behavior - Medical insurance fraud is characterized by a wide range of perpetrators, covert methods, and organized features, leading to significant erosion of limited medical insurance funds [2][5]. - The fraudulent behaviors include systematic fraud by medical institutions, fraud by insured individuals, and the illegal sale of medical insurance drugs [3][4]. Group 3: Legal Actions and Case Studies - The Supreme People's Court has published typical cases to demonstrate its commitment to combating medical insurance fraud and protecting the safety of medical insurance funds [1][3]. - A specific case from a private hospital in Shanxi highlights the severity of systematic fraud, where the hospital inflated drug prices and fabricated hospitalization costs, resulting in over 9.7 million yuan in fraudulent claims [4]. - Recent cases show that individuals involved in the illegal acquisition and sale of drugs purchased through fraudulent medical insurance schemes face severe legal consequences, with one individual sentenced to six years in prison for concealing and disguising criminal proceeds [5].

8月5日，国家医保局发文指出，按照国务院关于优化药品集采措施的部署要求，国家医保局坚持"稳临 床、保质量、防围标、反内卷"的原则，会同相关部门优化完善集采措施，指导国家组织药品联合采购 办公室（以下简称"药品联采办"）积极推进第十一批国家组织药品集采，确定了55种药品拟纳入采购范 围。 根据国家医保局方面披露，7月16日至31日，药品联采办组织开展相关药品信息填报工作。据药品联采 办统计，共480家企业提交了相关药品的资料信息，这些企业将作为医疗机构填报需求量的选择范围。 55个拟采购品种中，平均每个品种有15家企业，有3个品种的企业超过40家，企业数最多的达45家。 21点评：2018年以来，国家层面已经开展了十批药品集采，覆盖了435种药品，地方也相继开展了省级 和省际联盟集采，形成了协同补充的工作格局。 国家卫生健康委：医疗机构门诊命名不得使用暗示疗效名称 据央视新闻客户端8月5日报道，针对部分医疗机构使用模糊、笼统或容易混淆的门诊名称，少数医疗机 构为吸引患者，利用谐音、形容词等暗示疗效的门诊名称误导患者等情况，国家卫生健康委近日发布 《关于规范医疗机构门诊名称管理工作的通知》，强调医疗机构要遵循依法 ...

2025年8月5日，最高人民法院发布人民法院依法严惩医保骗保犯罪典型案例。在两起医保定点医疗机构 骗保案例中，医院负责人及其工作人员通过推行免费治疗、虚构住院费用等多种方式骗取巨额国家医保 基金，最后多人被判处有期徒刑。 最高法介绍，各级人民法院依法从严惩处医保骗保犯罪，重点打击幕后组织者、职业骗保人等。2024 年，全国法院一审审结医保骗保犯罪案件1156件2299人，一审结案数同比增长131.2%，挽回医保基金 损失4.02亿余元。 本案经重庆市沙坪坝区人民法院一审，重庆市第一中级人民法院二审，现已发生法律效力。人民法院经 审理认为，被告人杜某君作为定点医疗机构的实际控制人，指使工作人员弄虚作假，篡改医学检验数 据，制作虚假病历，使不需要住院的患者入院治疗，骗取医保费用，数额特别巨大，其行为已构成诈骗 罪。依法以诈骗罪判处被告人杜某君有期徒刑十二年，并处罚金人民币五十万元。 在另一起案例中，2016年9月，被告人艾某忠为主出资成立山西省大同市城区某医院有限公司并任法定 代表人。2018年初，该医院成为医保报销定点医院。2018年12月，医院更名为大同市平城区某医院有限 公司，法定代表人变更为艾某宇，但实际 ...

Core Viewpoint - Private hospitals play a significant role in enhancing medical resources and drug procurement, but some have engaged in fraudulent activities to defraud medical insurance funds, leading to legal consequences [3][5]. Group 1: Fraud Cases and Legal Actions - The Supreme People's Court reported on August 5, 2024, detailing severe punishments for medical insurance fraud, highlighting four typical cases of such crimes [3][5]. - A notable case involved a private hospital in Shanxi, where the accused inflated drug prices, duplicated drug entries, and fabricated medical records to defraud over 9.7 million yuan (approximately 1.5 million USD) from the medical insurance fund [4][5]. - The court sentenced the main perpetrator to 13 years and 6 months in prison, with fines imposed on several accomplices, reflecting the judiciary's strict stance against such fraudulent activities [4][5]. Group 2: Impact on Medical Insurance System - The Supreme Court emphasized that while private hospitals contribute to medical service provision, fraudulent practices undermine the integrity of the medical insurance system, necessitating strict legal action [5]. - In 2024, courts across the country concluded 1,156 cases of medical insurance fraud involving 2,299 individuals, marking a 131.2% increase in case resolution compared to the previous year, and recovering over 400 million yuan (approximately 56 million USD) in defrauded funds [5].

人民法院经审理认为，被告人艾某忠等人以非法占有为目的，通过虚增药品进价、药品重复入库、虚增 临床用药、检查费用、虚报床位、空挂病床等方式，大肆提高、虚构住院费用，制作假病历，将虚假数 据上传医保中心，共同骗取医疗保障基金，数额特别巨大，其行为均已构成诈骗罪。根据各被告人的犯 罪事实、犯罪性质和情节，依法以诈骗罪判处被告人艾某忠有期徒刑十三年六个月，并处罚金人民币五 十万元；被告人艾某宇有期徒刑十一年，并处罚金人民币二十万元；被告人张某才有期徒刑十年六个 月，并处罚金人民币十五万元；被告人李某有期徒刑十年，并处罚金人民币十万元；被告人张某国有期 徒刑十年，并处罚金人民币十万元；被告人牛某鹏有期徒刑十年，并处罚金人民币十万元；被告人赵某 有期徒刑四年，并处罚金人民币三万元（其他判项略）。 最高法表示，本案是民营医院及其工作人员通过虚增药品进价、药品重复入库、虚增临床用药、检查费 用、虚报床位、空挂床等方式骗取医保基金的典型案例。民营医院在充实医疗力量、保障人民群众就 医、购药方面发挥重要作用。但有的民营医院及其工作人员为获取非法利益，采用虚假手段骗取国家医 保基金，严重危害医疗保障制度健康持续发展，依法应予惩处。 ...

医保基金是人民群众的"看病钱""救命钱"。今天（5日），最高人民法院通报了2024年人民法院依法严 惩医保骗保犯罪，切实维护医保基金安全和人民群众医疗保障合法权益的情况，并发布了4件依法严惩 医保骗保犯罪典型案例。 在具体措施上： 一是制定指导意见。牵头起草《最高人民法院、最高人民检察院、公安部关于办理医保骗保刑事案件若 干问题的指导意见》，明确医保骗保犯罪定罪处罚、法律适用、政策把握、办案要求及有关工作制度机 制等。 二是开展专项整治工作。会同国家医疗保障局等有关部门开展2024年医保基金违法违规问题专项整治， 同步部署全国法院开展2024年医保基金违法违规问题专项整治工作。 三是依法严惩医保骗保犯罪。2024年，全国法院一审审结医保骗保犯罪案件1156件2299人，一审结案数 同比增长131.2%，挽回医保基金损失4.02亿余元。 四是制发《最高人民法院关于加强医保基金监管维护医保基金安全的司法建议书》。 发布4件典型案例 案例一虚增药品进价、空挂床……山西大同一民营医院骗取国家医保基金970余万元 2016年9月，被告人艾某忠为主出资成立山西省大同市城区某医院有限公司并任法定代表人。2018年 初，该医 ...

Core Viewpoint - The article highlights the increasing prevalence of healthcare fraud related to high-value drugs, particularly focusing on the misuse of the drug Semaglutide, which is impacting the integrity of the pharmaceutical market [2]. Group 1: Healthcare Fraud Cases - The National Healthcare Security Administration has reported typical cases of healthcare fraud involving pharmacies and hospitals, with high-value drugs being a major area of concern [2]. - A specific case in Shanghai involved an individual, Niu, who purchased Semaglutide injections excessively over a two-year period, exceeding the standard dosage for diabetes patients by over 800 days [2]. - Niu's parents were also found to have purchased excessive amounts of the same drug, with the father exceeding the standard dosage for over 800 days and the mother for over 700 days [2]. Group 2: Regulatory Actions - The Shanghai healthcare department mandated Niu to refund 23,258.03 yuan and suspended his network settlement for three months, with similar actions taken against his parents [2]. - The investigation revealed issues such as illegal procurement of drugs, lack of proper prescription review, fraudulent invoicing, and excessive prescriptions, which have been referred to law enforcement and health authorities for further action [2].