Harbin Medical Insurance Bureau issued a typical case of cracking down on fraudulent insurance fraud.

Weave a secret fund supervision network to build a medical insurance protection line. Recently, Harbin Medical Insurance Bureau issued a typical case of cracking down on fraud and insurance fraud.

First, Harbin People’s Dental Clinic illegally settled the medical insurance fund case.

According to the investigation of Harbin Medical Insurance Bureau, in 2019, in the process of providing services for the insured, Harbin People’s Stomatological Clinic was suspected of uploading and settling the medical expenses incurred in other medical institutions through this designated medical institution, involving 2 people, involving an amount of 4,000 yuan. According to Article 87 of People’s Republic of China (PRC) Social Insurance Law, Service Agreement of Designated Medical Institutions with Basic Medical Insurance in Harbin, and Paragraph 4 of Article 40 in Chapter 4 of Regulations on the Supervision and Administration of the Use of Medical Insurance Funds, Harbin Medical Security Bureau made a decision to terminate the service agreement, recover the illegal amount of 4,000 yuan and impose a fine of twice the illegal amount, with a total fine of 8,000 yuan.

2. The case of illegal settlement of medical insurance fund in Xuefu Store of Heilongjiang Hua Wei Kangjian Pharmacy Chain Co., Ltd.

During the special verification of multiple MAC addresses, Harbin Medical Security Bureau found that Xuefu Store of Hua Wei Kangjian Pharmacy Chain Co., Ltd. in Heilongjiang Province had privately connected to the medical insurance network and made medical insurance settlement. After investigation and verification, third-party data screening and comparison, it was confirmed that the store involved an illegal amount of 51,065.9 yuan. In accordance with Item (3) of Article 39 of Harbin Medical Insurance Designated Retail Drugstore Service Agreement (2020 Edition), the service agreement of this store shall be dissolved and the illegal expenses shall be recovered.

III. Case of illegal settlement of medical insurance fund in Dongxin Village Clinic of Zhoujia Town, Shuangcheng District

Harbin Audit Bureau found it during the audit of the medical insurance fund in Shuangcheng District in 2019 and was investigated by the Municipal Medical Insurance Bureau. After investigation and confession by the parties concerned, Fu Mopeng, a clinic in Dongxin Village, Zhoujia Town, Shuangcheng District, Harbin, defrauded the medical insurance fund of 164,611.52 yuan in the form of false medical expenses in 2018 (it has been returned to the medical insurance fund account). According to the Administrative Punishment Law of the People’s Republic of China and the Provisions on the Transfer of Suspected Criminal Cases by Administrative Law Enforcement Organs, Harbin Medical Security Bureau transferred the relevant evidential materials of the case to judicial organs. After trial by the people’s court, according to the facts and circumstances of the crime, the village doctor involved in the clinic was sentenced to fraud and fined.

4. Shuangcheng Renkang Hospital illegally settled the medical insurance fund case

After investigation by Harbin Medical Insurance Bureau and Harbin Medical Insurance Center, Harbin Shuangcheng Renkang Hospital inflated the medical expenses of medical insurance patients in the form of returning drugs to the library in 2017 -2018, and the medical insurance fund was 739,977.99 yuan after audit verification. After an extended inspection of the use of medical insurance funds in this hospital during 2018 -2019, it was found that the hospital violated the restrictions of drug list, such as drug use, string charges and other illegal acts, and induced the insured to be hospitalized by preferential medical treatment, which was suspected of defrauding the medical insurance fund. According to the relevant provisions of Article 87 of the Social Insurance Law of People’s Republic of China (PRC) and the relevant provisions of Article 66, paragraph 1, Chapter 7 of the Service Agreement for Designated Medical Institutions of Basic Medical Insurance for Urban Employees in Harbin, the service agreement of this hospital was terminated, the illegal medical insurance fund was recovered and handed over to judicial organs for handling.

V. The case of illegal settlement of medical insurance fund by Guofu Branch of Heilongjiang Jintian Aixin Pharmaceutical Chain Co., Ltd.

After investigation by Harbin Medical Security Bureau and Harbin Medical Security Service Center, Guofu Branch of Heilongjiang Jintian Aixin Pharmaceutical Chain Co., Ltd. was suspected of providing medical insurance settlement for non-designated institutions, involving 13,537.6 yuan. Harbin Medical Security Bureau and Harbin Medical Security Service Center terminated the designated medical insurance service agreement of the hospital in accordance with Article 87 of People’s Republic of China (PRC) Social Insurance Law and Article 37, paragraph 3 of Harbin Basic Medical Insurance Designated Medical Institutions Service Agreement; Guofu Store was ordered to return 13,537.6 yuan to the medical insurance fund, and was fined twice the amount defrauded, with a total fine of 27,075.2 yuan.

Six, Harbin Xiangfang District Happiness Hospital illegal settlement of medical insurance fund case.

After verification by Harbin Medical Insurance Bureau, Happiness Hospital in Xiangfang District of Harbin has unreasonable charges, drug use in violation of drug restrictions and other acts, and the total illegal expenses are 139,847.86 yuan. The hospital took the initiative to correct the violations and has returned all the illegal expenses of 139,847.86 yuan. According to Paragraph 6 and Paragraph 12 of Article 73 of Harbin Designated Medical Institutions Service Agreement (2020 Edition) and Paragraph 27 and Paragraph 36 of Article 2 of the scoring standard of the Measures for the Assessment of Service Quality of Designated Medical Institutions, the service qualification was suspended for one month, and the assessment score was deducted and linked to the assessment fund.

7. The case of illegal settlement of medical insurance fund by Chang ‘an Community Health Service Center in Tonghe County.

According to the investigation by Tonghe County Health Insurance Bureau, there are some problems in Changan Community Health Service Center in Tonghe County during 2020, such as unreasonable inspection, unreasonable treatment, excessive inspection, repeated charges, and charges exceeding the price, involving a total of 69,201.9 yuan in illegal expenses. Tonghe County Medical Security Bureau ordered Chang ‘an Community Health Service Center to return the illegal fees totaling 69,201.9 yuan and suspend its service agreement for one month according to the provisions of Article 66 of the Medical Service Agreement of Designated Medical Institutions of Tonghe County Medical Insurance.

8. Heilongjiang Dekang Hospital illegally settled the medical insurance fund case.

After investigation by the Yanshou County Medical Security Bureau, in April 2021, with the purpose of generating profits for the hospital, Dekang Hospital of Heilongjiang hired sitting doctors to persuade patients to take care of minor illnesses, and the insured who did not meet the admission indications were admitted to the hospital, resulting in the phenomenon of "hanging bed", which led to improper expenditure of 25,300 yuan from the medical insurance fund. According to Article 61 of the medical service agreement of medical insurance designated medical institutions in Yanshou County and other relevant regulations, the Yanshou County Medical Security Bureau fully recovered the illegal medical expenses of 25,300 yuan, and suspended the service agreement of designated medical institutions in Heilongjiang Dekang Hospital for three months.

Nine, shangzhi city Lianghe Town Center Health Center illegally settled the medical insurance fund case.

In the daily audit inspection, the handling center of shangzhi city Medical Insurance Bureau found that in 2020, four patients, including Wang, had decomposition hospitalization behavior, involving a violation amount of 4,870.65 yuan; The list of medical expenses of three patients in this hospital is inconsistent with the doctor’s advice, involving an illegal amount of 3677.39 yuan. According to the provisions of Articles 33 and 47 of the Interim Measures for the Supervision and Administration of Medical Security Fund in Heilongjiang Province, there are some problems in shangzhi city Lianghe Town Central Health Center, such as decomposition of hospitalization, the list of expenses inconsistent with the doctor’s advice, etc., and the amount involved in the violation shall be recovered. According to the provisions of Article 87 of People’s Republic of China (PRC) Social Insurance Law, a fine of three times the amount of violation was imposed.

X. Harbin Minsheng Hospital illegally settled the medical insurance fund case.

Harbin Medical Insurance Bureau and the Municipal Public Security Bureau jointly sent an inspection team to inspect the management and use of medical insurance funds in Binxian County from January 2018 to July 2020. During the inspection, it was found that Harbin Minsheng Hospital paid RMB 118,264.30 to the medical insurance fund for residents’ medical insurance exceeding the restrictive conditions and diseases’ drug use violations, and carried out MRI inspection for medical treatment projects exceeding the medical institution practice license, involving RMB 8,100 to the medical insurance fund for violations. According to the provisions of the tenth and twelfth paragraphs of Article 72 of the Service Agreement for Designated Medical Institutions of Binxian Medical Security Bureau, the paid illegal medical insurance fund of 126,364.30 yuan was recovered, deducting 150 points for urban and rural residents in 2020 and 100 points for urban workers in 2020. (Harbin Daily reporter Yu Yongzhen)