近日，国家医保局公布5起个人骗取医保基金典型案例，涵盖倒卖医保药品和伪造证明材料两大类违法 行为。从违法形式来看，既有参保人利用特殊病种待遇、低保人员医保待遇超量开药倒卖牟利，也有通 过隐瞒第三方责任、伪造受伤原因等虚假证明材料骗取医保报销。从违法后果来看，所有涉案人员均受 到刑事处罚，全额退赔骗取的医保基金。 河北省秦皇岛市关某等5人冒名就医和倒卖医保药品骗保案 2025年1月，河北省秦皇岛市医保部门收到相关部门移交的线索后，立即会同秦皇岛市港航公安机关开 展联合调查。经查，2023年2月至2024年12月，参保人关某为获取非法利益，通过刘某、孟某某、贾某 某、玄某某收集社会保障卡70余张，关某利用收集的这些社会保障卡，以代购药名义先后在秦皇岛市21 家医疗机构开具司美格鲁肽并骗取医保基金报销12万余元。随后，关某将购买的这些司美格鲁肽，通过 邮寄方式向湖北省武汉市、河南省开封市、天津市等地销售获利。 经公安机关查实，王某、孙某、杨某均不同程度参与了伪造证明材料、骗取医保基金的违法活动。2024 年4月，龙口市人民法院判决杨某犯诈骗罪，判处有期徒刑9个月，缓刑1年，并处罚金8000元；王某犯 诈骗罪，判处有 ...

Core Points - The article discusses a significant case of medical insurance fraud in Shanxi Province, where a hospital was involved in fraudulent activities to exploit the national medical insurance fund [1][9] - The case highlights various methods used by the defendants to inflate hospital admissions and costs, ultimately leading to substantial financial gains at the expense of the insurance system [5][7] Summary by Categories Fraud Methods - **Method 1: Increasing Fake Inpatients** The hospital recruited patients through incentives, paying referral fees to those who brought in new patients, thereby artificially inflating the number of hospital admissions [2][3] - **Method 2: Phantom Admissions** Some patients did not actually stay in the hospital but left their insurance cards there, allowing the hospital to create false medical records and claim reimbursements [3][4] - **Method 3: Inflating Treatment Costs** The hospital exaggerated the treatment costs for patients, even those with minor ailments, to reach the maximum reimbursement limits set by the insurance [5][6] - **Method 4: Financial Manipulation** The hospital submitted inflated drug costs to the insurance fund, with discrepancies between actual drug purchase prices and reported amounts, leading to significant overclaims [7][8] Legal Consequences - The main defendant, identified as Ai, was sentenced to 13 years and 6 months in prison, along with fines, while other co-defendants received varying sentences [9]

Core Points - A private hospital in Shanxi has transformed from a healthcare provider into a fraudulent entity, embezzling 9.7 million in medical insurance funds over three years [1][3] - The hospital's director organized a meeting to instruct staff on how to inflate medical claims, leading to widespread participation in the fraud [1][3] - The fraudulent practices included misdiagnosing patients and creating false medical records, which were eventually uncovered by the insurance bureau [1][3] Summary by Sections - **Fraudulent Activities**: The hospital engaged in blatant fraud by falsely diagnosing patients and inflating medical claims, treating patients as sources of income rather than individuals needing care [1][3] - **Involvement of Staff**: The scheme involved all levels of hospital staff, from nurses to financial personnel, indicating a systemic issue within the institution [3] - **Consequences**: The fraud was exposed in late 2020, resulting in the recovery of 9.7 million in embezzled funds, a 13.5-year prison sentence for the director, and the revocation of the hospital's medical insurance qualifications [3]

Employment and Economic Stability - The overall employment situation is stable, with the urban survey unemployment rate decreasing to 5.1% in October, down 0.1 percentage points from the previous month [1] - The average urban survey unemployment rate from January to October was 5.2%, with local registered labor at 5.3% and migrant labor at 4.7% [1] Real Estate Market Trends - In October, new residential sales prices in first-tier cities fell by 0.8% year-on-year, while second-tier cities saw a 2.0% decline and third-tier cities a 3.4% decline [1] - The second-hand housing prices in first-tier cities dropped by 4.4%, with second-tier cities down 5.2% and third-tier cities down 5.7% [1] - The spokesperson from the National Bureau of Statistics indicated that the real estate market is undergoing a transformation that requires time, and fluctuations in certain indicators should be viewed objectively [1] Bird Protection and Wildlife Crime - The Ministry of Public Security has launched a campaign to combat wildlife crimes, particularly those harming bird species, with a focus on dismantling criminal networks and seizing illegal tools [4] - The National Forestry and Grassland Administration reported an increase in protected bird species, with 1,028 species now classified as "three protected" [6] Gold Mining Discovery - A significant discovery of a low-grade, large-scale gold mine, the Dadongou Gold Mine, has been made in Liaoning Province, with a total metal content of 1,444.49 tons, marking it as the largest single gold mine discovered since the founding of New China [7] - The mine has a total ore volume of 2.586 billion tons and an average grade of 0.56 grams per ton, with a promising economic outlook for development [7] Healthcare Fraud Cases - The National Healthcare Security Administration has reported four cases of healthcare fraud involving pharmacies, with the highest case amounting to over 3.3 million yuan [8] - The cases include organized schemes to defraud insurance funds through false prescriptions and collusion with intermediaries [8] E-commerce Trademark Infringement - The State Administration for Market Regulation is seeking public input on new regulations to assist in addressing trademark infringement in e-commerce, highlighting the challenges posed by "ghost stores" with false registration information [9] - In the first three quarters of the year, 27,000 trademark infringement cases were handled, involving 468 million yuan [9] Three Gorges Project Development - During the 14th Five-Year Plan, the Three Gorges Project has allocated 46.91 billion yuan for 1,235 projects aimed at improving the livelihoods of relocated residents and promoting economic development in the reservoir area [10] - The average disposable income for rural migrants in the Three Gorges area is projected to reach 22,000 yuan in 2024, a 4.19-fold increase since 2010 [10]

Core Viewpoint - The article discusses a significant case of medical insurance fraud in Datong, Shanxi Province, where a hospital was involved in fraudulent activities to illegally obtain funds from the national medical insurance system, highlighting the serious implications for public trust and the integrity of the healthcare system [1][15]. Summary by Sections Fraud Methods - **Method 1: Increasing Fake Inpatients** The hospital recruited patients, offering referral fees to those who brought in new patients, thereby inflating the number of hospital admissions [2][3]. - **Method 2: Phantom Admissions** Some patients did not actually stay in the hospital but left their insurance cards with the hospital, which then fabricated medical records and treatment documents to claim reimbursements [3][4]. - **Method 3: Inflating Treatment Costs** The hospital manipulated treatment records to elevate costs to the maximum reimbursement limit, even for minor ailments, by adding unnecessary treatments and medications [7][9]. - **Method 4: Financial Fraud** The hospital engaged in financial misreporting by inflating the costs of medications and treatments, submitting false data to the insurance system to claim higher reimbursements than actual expenses [11][13][17]. Legal Consequences - The main perpetrator, Ai Mouzhong, was sentenced to 13 years and 6 months in prison, with fines imposed on him and other co-defendants, reflecting the severity of the fraud and its impact on the healthcare system [18].

Core Viewpoint - The article highlights the ongoing misuse of medical insurance cards in China, where non-medical products are being fraudulently classified as medical devices to allow consumers to purchase everyday items using their insurance funds [1][3][5]. Group 1: Misuse of Medical Insurance Cards - Various pharmacies are openly promoting the ability to use medical insurance cards for purchasing daily necessities, such as toothbrushes and skincare products, which violates regulations that restrict insurance funds to medical-related expenses [3][5]. - Investigations reveal that some products, like "dental brushes" and "medical dressings," are essentially ordinary items but are labeled as medical devices to facilitate insurance payments [7][10][14][17]. - A significant number of consumers are being encouraged to exploit these loopholes, with online platforms sharing strategies for using insurance cards to buy non-medical items [3][5]. Group 2: Pharmaceutical Companies' Role - Companies are producing everyday products under the guise of medical devices, claiming they are "cleaner and safer" to attract consumers and increase profits [24][26]. - A specific company reported a substantial contract worth 90 million yuan for supplying these products to nearly 20,000 pharmacies, indicating a lucrative market for such practices [26][28]. - The production of these items is described as legal and compliant, as they possess the necessary medical coding to qualify for insurance payments, despite their actual use being unrelated to medical care [30][28]. Group 3: Impact on the Market - In Gansu, a chain of pharmacies is prominently displaying "medical skincare products" that are registered as medical devices, allowing them to be purchased with insurance funds, despite being marketed as regular skincare items [32][34]. - The profitability of pharmacies is closely tied to the ability to process insurance claims, leading to aggressive promotion of these products [38][39]. - A specific company revealed that approximately 60% of its sales in Gansu are processed through insurance payments, amounting to an estimated 6 million yuan being drawn from consumers' insurance accounts [45].

Core Viewpoint - The article highlights the ongoing misuse of medical insurance cards in China, where non-medical products are being fraudulently classified as medical devices to allow consumers to purchase them using their insurance funds, despite regulations prohibiting such practices [1][3][5]. Group 1: Misuse of Medical Insurance Cards - Various stores are openly promoting the ability to use medical insurance cards for purchasing everyday items like toothbrushes and skincare products, which are not intended for medical use [3][7]. - Consumers have reported finding guides online that instruct them on how to exploit their insurance cards for non-medical purchases [3][7]. - The Chinese Social Insurance Law explicitly states that medical insurance funds should only be used for medical-related expenses, yet violations continue to occur [5]. Group 2: Specific Examples of Misclassification - In multiple pharmacies, items such as dental cleaning devices and "medical toothbrushes" are sold, which are essentially regular products but labeled differently to qualify for insurance payments [9][10]. - A pharmacy in Chengdu allowed the purchase of contact lenses labeled as medical devices, despite official confirmation that they should not be eligible for insurance payment [12][14]. - Products like sunscreen sleeves and masks are being marketed as "medical isolation pads" to enable insurance payment, despite their actual use being for sun protection [22][23][33]. Group 3: Company Practices and Financial Implications - Companies are taking advantage of the loophole by branding everyday items as medical devices, thus increasing their market share and profits, with one company reporting a contract worth 90 million yuan for such products [29][31]. - The practice of selling "medical skincare products" in pharmacies is prevalent, with companies reporting significant sales figures, indicating that a large portion of their revenue comes from insurance payments [37][45][53]. - In one case, a company revealed that approximately 60% of its sales in a specific region were made using medical insurance cards, amounting to around 6 million yuan being drawn from consumer insurance funds [53].

Core Viewpoint - The article highlights the controversy surrounding Aier Eye Hospital's charitable activities, suggesting that the company may be profiting from its donations through a mechanism that allows funds to flow back to its own accounts, raising ethical concerns about its operations [2][3]. Group 1: Charitable Activities and Controversies - Aier Eye Hospital has faced scrutiny for its charitable donations, with reports indicating a "left hand donates, right hand receives" model that potentially allows the company to profit from medical insurance funds [2][3]. - In 2025, Aier Eye Hospital ranked 19th on the "China Charity List" with total donations of 21.672 million yuan, but the legitimacy of these donations has been questioned [3]. - The company has been accused of requiring beneficiaries to seek treatment at its own facilities, leading to funds ultimately returning to Aier Eye Hospital [4]. Group 2: Financial Performance and Market Position - Aier Eye Hospital's financial performance has shown signs of stagnation, with a net profit of 2.051 billion yuan in the first half of 2025, reflecting a mere 0.05% increase year-on-year [8]. - The company's stock price has declined, closing at 12.55 yuan per share on October 17, 2025, which is a drop from 13.25 yuan at the beginning of the year, indicating a lack of market confidence [9][10]. - Despite aggressive acquisitions since 2011, Aier Eye Hospital's growth rate has slowed significantly, with 2024 marking the lowest annual growth rates in revenue and net profit [8][9]. Group 3: Regulatory Issues and Compliance - Aier Eye Hospital has faced multiple penalties for insurance fraud, with specific cases involving improper billing practices and violations of medical insurance regulations [6]. - The company has been linked to a pattern of complaints regarding its practices, including allegations of misleading patients into unnecessary surgeries under the guise of free medical services [5][6]. Group 4: Business Expansion and Asset Growth - Aier Eye Hospital has expanded aggressively through acquisitions, with total assets reaching 35.269 billion yuan by mid-2025, a significant increase from 1.722 billion yuan in 2011 [7]. - The company has made notable acquisitions, including a 12 billion yuan purchase of a European chain in 2017 and a 6.5 billion yuan acquisition in 2025 [7][8].

Core Viewpoint - The article emphasizes the importance of safeguarding the medical insurance fund, which is crucial for the public's healthcare needs, and highlights the government's zero-tolerance policy towards fraudulent activities related to medical insurance [2]. Group 1: Fraud Cases - In Jiangsu Province, a case involved an individual named Jing who exploited special disease insurance benefits by faking medication needs and selling high-priced drugs, resulting in a loss of over 280,000 yuan to the medical insurance fund [3]. - In Guizhou Province, Zhao orchestrated a scheme where he instructed patients to over-prescribe medications and then sold them, leading to a total loss of 282,392.52 yuan from the medical insurance fund [4][5]. - In Jiangxi Province, an individual named Xiao used another person's social security card to fraudulently obtain and sell medication, causing a loss of 75,613.44 yuan to the medical insurance fund [6]. - In Shaanxi Province, Peng exploited the medical insurance benefits of deceased individuals to sell drugs, resulting in a loss of 60,769.96 yuan [7]. - In Gansu Province, a person named Heng created a network to sell medications using others' insurance information, defrauding the medical insurance fund of 369,772.72 yuan [9]. - In Sichuan Province, Qian used the identity of a deceased person to obtain and sell medication, causing a loss of 13,815.90 yuan [10]. - In Fujian Province, a group of patients conspired to over-prescribe medications and sell them, leading to a total loss of 331,962.42 yuan from the medical insurance fund [11][12]. - In Qinghai Province, Bai was found to have fraudulently used another person's identity to claim medical expenses, resulting in a loss of 37,879.4 yuan [13]. - In Ningxia, an individual named Ou allowed others to use his social security card for fraudulent claims, involving 11,984.66 yuan [14]. - In Hunan Province, Li and a pharmacy owner colluded to forge documents and defraud the medical insurance fund of 35,000 yuan [15]. - In Inner Mongolia, Ma was found to have submitted forged medical records to claim benefits, resulting in a loss of 7,953 yuan [16]. Group 2: Government Actions - The National Medical Insurance Administration has taken a strong stance against fraud, showcasing a series of typical cases to educate the public and deter similar activities [2][17]. - The article highlights the collaboration between medical insurance departments and law enforcement to investigate and prosecute fraudulent activities, ensuring accountability and recovery of lost funds [3][4][5][6][7][8][9][10][11][12][13][14][15][16].

Core Insights - The National Healthcare Security Administration (NHSA) of China has announced seven typical cases of individual fraud against the healthcare insurance system, marking the first public disclosure since the initiation of a special rectification campaign for healthcare fund management issues [1][2]. Group 1: Fraud Cases - The seven cases involve various fraudulent activities, including impersonation for medical treatment and the resale of healthcare drugs [1]. - Specific cases include: - A case in Shenzhen where an individual named Li impersonated others to obtain medical services and resold drugs [1]. - A couple in Beijing involved in reselling healthcare drugs [1]. - Individuals in Hubei and Shanghai also implicated in similar drug resale schemes [1]. - A case in Xinjiang involving false invoicing for reimbursement [1]. - A case in Jilin where an individual sought double reimbursement for medical expenses already paid by a third party [1]. - A case in Tianjin involving impersonation for medical treatment [1]. Group 2: Regulatory Measures - Big data screening has played a crucial role in identifying these fraudulent activities, with the Shenzhen healthcare bureau utilizing data models to monitor abnormal prescription behaviors [2]. - The NHSA has emphasized a "zero tolerance" policy towards fraud, indicating that regulatory efforts will be intensified through the use of technology such as drug traceability codes and enhanced inter-departmental collaboration [2].