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 ...

国家医保局公布5起个人骗取医保基金典型案例 中新网12月1日电 据国家医保局网站消息，为进一步强化全民医保法治意识、深化警示教育效果，巩固 对欺诈骗保行为的高压态势，彰显守护医保基金安全的坚决态度，国家医保局现发布第四期5起个人骗 取医保基金典型案例。 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。 2025年5月13日，港航公安局将关某、刘某、孟某某、贾某某、玄某某5名犯罪嫌疑人移送海港区人民检 察院审查起诉。目前，案件正在海港区人民检察院审查起诉中。经查，关某为公职人员，2025年5月26 日已将关某案件同步移送秦皇岛市纪检监察机关。 案例二 安徽省芜湖市参保人肖某倒卖医保药品骗保案 2024年8月，安徽省芜湖市 ...

Core Viewpoint - The National Medical Insurance Administration emphasizes the importance of safeguarding the medical insurance fund and has released five typical cases of individual fraud to strengthen legal awareness and deter fraudulent activities [1] Group 1: Case Summaries - Case 1: In Qinhuangdao, Hebei, an individual named Guan and four accomplices collected over 70 social security cards to fraudulently obtain 120,000 yuan in reimbursements for a drug, which they then sold in other provinces [2] - Case 2: In Wuhu, Anhui, an individual named Xiao exploited his medical condition to obtain excess medication, selling the surplus for a total fraud of 51,950.91 yuan [3] - Case 3: In Zhengzhou, Henan, Zhang falsified injury details to claim 39,477.26 yuan in reimbursements after already receiving compensation from his employer for a work-related injury [4] - Case 4: In Yantai, Shandong, Wang and two accomplices misrepresented a work-related injury as a home accident, resulting in a fraudulent claim of 18,070.63 yuan [5][6] - Case 5: In Benxi, Liaoning, Liu misrepresented a traffic accident to claim 6,549.11 yuan from the medical insurance fund, which was ultimately recovered [7] Group 2: Fraud Patterns and Consequences - The five cases illustrate two main types of fraud: selling medical drugs and falsifying documentation to claim reimbursements [8] - All individuals involved faced criminal penalties and were required to fully repay the defrauded medical insurance funds, highlighting the serious legal repercussions of such actions [8] - The National Medical Insurance Administration warns the public against engaging in fraudulent activities, stressing the importance of adhering to medical insurance laws and protecting personal rights [8]

央视网消息：医保基金作为人民群众的"看病钱""救命钱"，绝不容许任何形式的侵占、挪用与骗 取。为进一步强化全民医保法治意识、深化警示教育效果，巩固对欺诈骗保行为的高压态势，彰显守护 医保基金安全的坚决态度，国家医保局现发布第四期5起个人骗取医保基金典型案例。 案例一 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。 2025年5月13日，港航公安局将关某、刘某、孟某某、贾某某、玄某某5名犯罪嫌疑人移送海港区人 民检察院审查起诉。目前，案件正在海港区人民检察院审查起诉中。经查，关某为公职人员，2025年5 月26日已将关某案件同步移送秦皇岛市纪检监察机关。 案例二 安 ...

Core Viewpoint - The article discusses the introduction of the commercial insurance innovative drug directory in China, which supplements the basic medical insurance directory and aims to include high-priced innovative drugs that provide significant clinical value and patient benefits [2][10]. Summary by Sections Introduction of the Commercial Insurance Innovative Drug Directory - The National Healthcare Security Administration announced a list of drugs that passed the initial review for the commercial insurance innovative drug directory, with a total of 121 drugs, over half of which are cancer or rare disease medications [2][5]. - The directory is expected to include high-priced drugs, such as CAR-T therapies costing over 1 million yuan per injection and gene therapies priced around 98,000 yuan per injection [2][4]. Drug Approval and Characteristics - To qualify for the commercial insurance innovative drug directory, drugs must either be newly approved from January 1, 2020, to June 30, 2025, or have indications included in the national rare disease directory by June 30, 2025 [5]. - Among the 121 drugs, 57 are imported, accounting for 47%, with notable entries from companies like Pfizer and Johnson & Johnson [5]. Focus on Cancer and Rare Diseases - The majority of drugs that passed the initial review are cancer treatments, with over 40 entries, followed by 35 for rare diseases [5][6]. - The article highlights the potential for the directory to alleviate payment challenges for rare disease medications, with companies actively submitting applications [6]. Pricing and Negotiation Challenges - The pricing negotiation process for drugs in the commercial insurance directory remains uncertain, as it involves collaboration between the National Healthcare Security Administration, commercial insurers, and pharmaceutical companies [12][13]. - The article notes that the commercial insurance directory may serve as a "double insurance" for companies, allowing them to apply for both the basic medical insurance and the commercial insurance directories simultaneously [9]. Future Considerations and Recommendations - The article suggests that the implementation of the commercial insurance innovative drug directory requires further exploration and refinement, with recommendations for pilot programs in specific insurance products [14]. - It emphasizes the need for insurance companies to develop reasonable pricing mechanisms and improve data integration with basic medical insurance to enhance their pricing strategies [13][14].

Core Insights - The National Healthcare Security Administration (NHSA) has released a list of drugs that passed the preliminary review for the commercial insurance innovative drug directory, which is a new supplement to the basic medical insurance directory aimed at covering high-priced drugs [2][3] - A total of 121 drugs have passed the initial review, with over half being cancer or rare disease medications, including several high-cost therapies [2][5] - The final commercial insurance innovative drug directory is expected to be published between October and November 2023, following expert evaluations and price negotiations [2][3] Summary by Category Drug Characteristics - The drugs included in the commercial insurance innovative drug directory are characterized by high innovation, significant clinical value, and substantial patient benefits, exceeding the basic insurance's "basic protection" scope [2] - Among the 121 drugs, 57 are imported, accounting for 47%, with notable entries from companies like Pfizer, Johnson & Johnson, and Merck [5] Pricing and Negotiation - The drugs will undergo price negotiations, which may lead to price reductions, but the extent of these reductions remains uncertain [9][10] - The commercial insurance innovative drug directory allows for simultaneous applications to both the basic medical insurance and the commercial insurance directories, providing a "double insurance" for companies [7] Market Dynamics - The directory includes a variety of drugs, including CAR-T therapies priced around 1 million yuan per injection, which have faced challenges in entering the basic medical insurance directory [6][9] - The directory's implementation may alleviate payment difficulties for rare disease medications, with companies actively submitting applications [6][8] Insurance Industry Considerations - The insurance industry faces challenges in pricing and market growth potential due to the voluntary nature of commercial insurance participation [9][11] - There is a need for better data integration between commercial insurance and basic medical insurance to enhance pricing strategies and product development [11]