The National Healthcare Security Administration sets a "red line" for insurance fraud: insured individuals will also be penalized if they encounter these situations

Today (the 1st), the Implementing Rules for the Regulations on the Oversight and Administration of the Use of the Medical Insurance Fund have come into effect. Fraudulent actions such as reselling and routing back prescription drugs, swapping medical insurance-covered medicines, and engaging in false medical treatment will be重点 addressed.

According to the Implementing Rules, the focus will be on cracking down on issues involving designated medical and pharmaceutical institutions using methods such as “pickup-and-drop-off service (car-to-car),” reducing or waiving fees, giving kickbacks, and gifting items like rice, noodles, and cooking oil to commit insurance fraud.

Gu Rong, director of the Fund Supervision Division of the National Healthcare Security Administration: Designated medical and pharmaceutical institutions can be deemed to be committing insurance fraud if they use methods such as persuasion and false advertising to unlawfully reduce fees, provide additional goods or services, and thereby induce or guide others to purchase medicines for medical insurance under another person’s name or through false medical treatment. For personal conduct under item 2 of Article 32 of the Implementing Rules, if a person knowingly participates in the illegal activities organized by others that commit insurance fraud, and accepts gifts of goods and reduced fees or provides additional services, they can be punished for insurance fraud.

After designated medical and pharmaceutical institutions organize others to buy medicines and medical consumables through medical insurance fraud, and then engage in illegal purchasing, sales, and other circumstances, they will be punished as “assisting others to purchase medicines under another person’s name or through false medical treatment,” with a fine of not less than 2 times and not more than 5 times the amount defrauded; and suspension of relevant responsible departments of the medical and pharmaceutical institution for medical services involving the use of the medical insurance fund for more than 6 months and less than 1 year.

If a designated medical and pharmaceutical institution fails to use the traceability codes for medicines and consumables as required and refuses to make corrections, it will be fined from RMB 10,000 to RMB 50,000.

Insured persons with the following circumstances will also be subject to punishment:

Submitting the same medical expense for oneself to the medical security administering body two times or more, and enjoying medical security benefits;

Submitting medical expenses that have already been paid by the work-related injury insurance fund or borne by a third party for medical insurance settlement, and enjoying medical security benefits;

Long-term handing over one’s medical insurance credentials to others for use, and receiving returned cash, physical goods, or other illegal benefits.

Gu Rong, director of the Fund Supervision Division of the National Healthcare Security Administration: For professional insurance-fraud persons such as medicine vendors, who, for a long time or repeatedly, purchase and sell medical-insurance-covered medicines to and from unspecified trading counterparties, it can be determined that they have an intent to commit insurance fraud. If insured persons resell medicines, medical consumables, medical service items, and so on whose purchase has already been paid for by the medical insurance fund, it can be determined that they are engaged in the resale of medicines as provided for in the Regulations.

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Responsible editor: Cao Ruitong