Jiangsu Anti-fraud Medical Insurance Fund: 29.44 million yuan recovered

Xiao Bowei, deputy director of Jiangsu Medical Security Bureau and spokesman of Jiangsu Medical Security Bureau, announced in Nanjing that Jiangsu Province had launched a special action to combat fraud and obtain medical security funds. From October last year to the end of January this year, more than 15,000 designated medical institutions were inspected in Jiangsu Province, covering more than 49% of the total. 9112 cases of violations were verified and recovered. The fund is 29.44 million yuan. On the same day, the Jiangsu Medical Security Bureau held a news briefing in Nanjing, announcing the special action of Jiangsu Province to combat fraud in obtaining medical security funds, and issued a notice on the Interim Measures for reporting and rewarding fraud in obtaining medical security funds. Xiangbowei said that although some achievements have been made in the special actions of fund supervision, we must also realize clearly that the task of strengthening fund supervision is a long way to go. At present, the awareness of all sectors of society about the security of the fund is not enough, and the laws and regulations of medical security need to be improved. Fund supervision points are long and extensive. There are not only fraudulent insurance in some designated medical institutions and pharmacies, but also violations of laws and regulations by a few insured personnel. We must take comprehensive measures to strengthen supervision and accelerate the formation of a work situation in which all sectors of society work together. Zhao Hui, deputy director of fund supervision department of Jiangsu Medical Security Bureau, introduced the announcement on the Interim Measures for reporting and rewarding fraudulent medical security funds at the ventilation meeting on the same day. Zhao Hui said that when reporting fraud in obtaining medical security funds, the fraudulent insurance amount involved in the report was rewarded according to the three-tier ratio, with the maximum reward amount not exceeding 100,000 yuan. The reward criteria for reporting fraud are as follows: in the first file, if the amount of fraud insurance is less than 50,000 yuan, the reward shall be given according to 5% of the amount of fraud insurance. In the second stage, rewards shall be given to those who report and verify fraud insurance amounts ranging from 50,000 yuan to 150,000 yuan according to 4% of the verified amount. In the third tier, rewards shall be given to those who report and verify the amount of fraud insurance in excess of 150,000 yuan according to 3% of the verified amount.

Zhao Hui said that the fraudulent behavior of obtaining medical security fund in this method mainly includes: fraudulent insurance behavior involving designated medical institutions and their staff; fraudulent insurance behavior involving designated retail pharmacies and their staff; fraudulent insurance behavior involving insured personnel; fraudulent insurance bank involving staff of medical security agencies. For; other fraudulent behavior of obtaining medical insurance fund.

Taking fraudulent insurance practices involving designated medical institutions and their staff as an example, the notification stipulates the following actions: fabricating medical services, forging medical documents and bills, defrauding medical security funds; providing false invoices for insured personnel; recording medical expenses that should be borne by individuals into the payment scope of the medical security fund; and Personnel who do not belong to the scope of medical security shall receive medical security treatment; those who provide credit card booking services for non-designated medical institutions; those who are registered for hospitalization; those who exchange drugs, consumables, articles and medical items to defraud the expenditure of medical security funds; and other fraudulent insurance practices of designated medical institutions and their staff. Xiangbowei said that next step, Jiangsu will continue to maintain the high-pressure situation of combating fraud insurance, strive to improve the regulatory mechanism of health insurance funds, accelerate the implementation of overall regional intelligent monitoring coverage, and constantly improve the risk prevention ability of agencies.