How Do I Identify Medicare Fraud?

In order to strengthen the management of the collection and use of medical insurance funds, strictly investigate and deal with medical insurance fraud, and ensure the safe, legal, and effective use of medical insurance funds, according to the "Social Insurance Law of the People's Republic of China", "Interim Regulations on the Collection of Social Insurance Fees", Relevant laws and regulations, such as the Labor Security Supervision Regulations, are formulated in accordance with the actual conditions of the province.

Administrative Measures on Anti-Fraud of Medical Insurance in Yunnan Province

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In order to strengthen the management and collection of medical insurance funds, strictly investigate and punish medical insurance fraud, and ensure the safe, legal, and effective use of medical insurance funds, according to the "

Full text of Yunnan province's medical insurance anti-fraud management measures ^[1]

Article 1 In order to strengthen the management of the collection and use of medical insurance funds, strictly investigate and punish medical insurance fraud, and ensure the safe, legal and effective use of medical insurance funds, according to the "Social Insurance Law of the People's Republic of China" ^[2] Relevant laws and regulations, such as the Provisional Regulations ^[3] and the Labor Security Supervision Regulations, are formulated in accordance with the actual conditions of the province.

Article 2 Medical insurance fraud referred to in these measures refers to the medical insurance fund caused by citizens, legal persons or other organizations in the process of participating in medical insurance, paying medical insurance premiums, and enjoying medical insurance treatment, intentionally fabricating facts, falsifying, and concealing the true situation Losing behavior.

The term "medical insurance anti-fraud" as mentioned in these Measures refers to behaviors of social insurance, development and reform, public security, public security, finance, health, food and drug supervision and other relevant administrative departments to prevent, investigate and deal with medical insurance fraud. ^[1]

The medical insurance anti-fraud staff members mentioned in the present Measures refer to the staff members of the social insurance administrative department who have qualifications for administrative law enforcement and hold administrative law enforcement certificates.

Article 3 These Measures apply to anti-fraud work such as basic medical insurance for urban employees, basic medical insurance for urban residents, various supplementary medical insurance, and medical insurance for retired cadres within the administrative region of the province.

Article 4 Anti-fraud work of medical insurance shall follow the principles of objectivity, fairness, impartiality and legality.

Article 5 Provincial, state (city), county (city, district) social insurance administrative departments and development and reform, public security, finance, health, food and drug supervision and other relevant administrative departments are responsible for the anti-fraud work of medical insurance across the province.

The social insurance administrative department shall perform the following duties in the medical insurance anti-fraud work:

(1) to guide and coordinate the anti-fraud work of medical insurance;

(2) to accept reports and complaints of fraudulent acts of medical insurance;

(3) Investigating and punishing medical insurance fraud;

(4) transferring medical insurance fraud cases that should be handled by other relevant functional departments;

(5) rewarding reporters;

(6) Supervising and inspecting the employer's participation in the medical insurance and the participation of the insured persons in receiving medical insurance benefits; ^[1]

(7) Supervising and inspecting designated medical service institutions such as designated medical institutions and designated retail pharmacies;

(8) Engaging social intermediary agencies to audit the financial status, salary payment, and payment of medical insurance premiums of the investigated objects; employing medical experts or qualified appraisal agencies and professionals to provide consultation on the medical behavior and standards of the investigated objects Suggest.

Development and reform, public security, finance, health, food and drug supervision and other departments, in accordance with their respective functions, strengthen supervision of medical insurance fraud, and assist the social insurance administrative department to recover the fraudulent medical insurance funds.

The supervisory authority supervises and inspects the performance of social insurance and other relevant government functional departments and their staff members in performing their duties in the medical insurance anti-fraud work.

Article 6 During the collection and payment of medical insurance funds, the following acts by payment units and individuals with the purpose of evading payment obligations and causing losses to the medical insurance funds are fraudulent:

(1) Forging or altering a social insurance registration certificate;

(2) Failure to declare truthfully the number of workers, paid wages and other information;

(3) Forging, altering, or deliberately destroying books or materials related to the payment of medical insurance or the absence of books, which makes it impossible to determine the base of medical insurance payment;

(4) Other frauds that violate medical insurance laws and regulations.

Article 7 In the payment link of the medical insurance fund, the following acts by units and individuals for the purpose of deceiving medical insurance treatment and causing losses to the medical insurance fund are fraudulent acts:

(1) Lending my identity certificate and social security card to others for illegal use; ^[1]

(2) fraudulent use of another person's identity certificate or social security card;

(3) Forging or using medical documents and medical fee bills such as false medical records, prescriptions, inspection and laboratory reports, and disease diagnosis certificates;

(4) concealing or fabricating the true reasons for admission to a false hospitalization;

(5) Other frauds that violate medical insurance laws and regulations.

Article 8 The following acts by designated medical institutions for the purpose of obtaining medical insurance benefits and causing losses to the medical insurance fund are fraudulent acts:

(1) allowing or inducing non-insured persons to be hospitalized in the name of the insured persons;

(2) applying medical expenses that should be paid by the insured person at their own expense to the medical insurance pooling fund;

(3) providing a false disease diagnosis certificate for hospitalization;

(4) failing to confirm the identity or illness of the insured person, and placing the outpatients in the hospital by name or by name;

(5) providing unnecessary or excessive medical services to the insured;

(6) Consolidating the expenses incurred by the non-designated medical institution into the expenses of the designated medical institution to settle with the medical insurance agency;

(7) Assisting the insured to set up a personal account fund or a unified fund for medical insurance;

(8) unauthorized charging behaviors such as raising the charging standards, adding items to be charged, splitting the charges, repeating the charges, and expanding the scope of charges;

(9) Replacement of non-medical insurance diseases, drugs, diagnosis and treatment items, medical service facilities, and health products, food, daily necessities with medical insurance diseases, drugs, diagnosis and treatment items, and medical service facilities are included in the medical insurance payment scope To collect medical insurance funds;

(10) Fraudulent use of fraudulent reports or false data to obtain medical insurance funds.

(11) Other frauds that violate medical insurance laws and regulations.

Article 9 The following acts of designated retail pharmacies for the purpose of deceiving medical insurance treatment and causing loss of medical insurance funds are fraudulent:

(1) Cashing out personal account funds in the medical insurance card for the insured person; ^[1]

(2) Selling medicines for non-designated retail pharmacies and issuing medical insurance cards on behalf of them;

(3) Selling food, cosmetics, daily necessities and other items and equipment not covered by medical insurance directly or in disguised form;

(4) the price for purchasing medicines by medical insurance cards is higher than the price of buying medicines in cash;

(5) fraudulent use of false reports or false data to obtain medical insurance personal account funds;

(6) Other frauds that violate medical insurance laws and regulations.

Article 10 If a medical insurance agency considers that a designated medical institution, a designated retail pharmacy or an insured person is suspected of fraud when applying for medical insurance treatment, it shall conduct a written inspection within 15 working days from the date of receiving the medical insurance treatment application Later, if the fact of fraud is found to exist, the relevant evidence materials shall be transferred to the social insurance administrative department within 5 working days, and the social insurance administrative department shall investigate and deal with it in accordance with relevant regulations.

Article 11 The administrative department of social insurance shall have the right to request relevant units and parties to provide relevant materials and statements for suspected medical insurance fraud cases that are found or received a complaint during the inspection, and shall promptly file the case if they consider it necessary to investigate and handle it.

Article 12 When investigating medical insurance fraud cases, medical insurance anti-fraud staff members may adopt the following methods:

(1) entering relevant production and operation sites to inquire relevant personnel about the investigation matters;

(2) Require the parties to provide relevant financial account statements, employee files, medical documents, expense notes and other materials, and make explanations and explanations;

(3) Collecting relevant information and information by means of inspection, recording, sound recording, video recording, photographing or copying;

(4) to seal materials that may be transferred, concealed or lost;

(5) Other investigation methods prescribed by laws and regulations. ^[1]

Any suspected case of medical insurance fraud investigated by the medical insurance anti-fraud staff has a direct interest with himself or his close relatives, and should be avoided.

Article 13 The administrative department of social insurance shall handle cases involving medical insurance fraud within 60 working days from the date of filing. If the situation is complicated, it may be extended for 30 working days upon approval by the person in charge of the social insurance administrative department.

Article 14 Cases which, after investigation by the social insurance administrative department, deem necessary to be transferred to other relevant government functional departments, shall be transferred in a timely manner. After the relevant government functional departments have dealt with it according to law, they should report the situation to the social insurance administrative department.

Article 15 Citizens, legal persons and other organizations have the right to report and complain about fraud in medical insurance.

Article 16 Where the reported case is verified, the social insurance administrative department shall reward the signed reporter.

If there are two or more informants in the same case, the first informant shall be the reward object.

Article 17 Reporting rewards are conducted in accordance with the following procedures:

(1) The social insurance administrative department investigates and verifies the report;

(2) the social insurance administrative department issues bonuses;

(3) If the whistleblower fails to receive the bonus within 30 days from the date of receiving the notification of the award, the award shall be deemed to have been waived.

Article 18 Reporting reward standards:

(1) If the reported case involves less than 10,000 yuan, the reward is 500 yuan;

(2) If the reported case involves an amount of less than 10,000 yuan to less than 20,000 yuan, the reward is 1,000 yuan;

(3) If the reported case involves an amount between 20,000 and 40,000 yuan, a reward of 1,500 yuan will be awarded; ^[1]

(4) If the reported case involves an amount of more than 40,000 yuan, the reward will be 5% of the amount involved, and the maximum award amount shall not exceed 10,000 yuan.

Article 19 The social insurance administrative department and its related staff shall abide by the following provisions when accepting and handling reported cases:

(1) not to disclose the name, unit, and address of the reporter;

(2) not to report materials to the unit under investigation or the person under investigation;

(3) Propaganda reports and rewards to reporters, without the consent of the reporter, shall not publicly or implicitly disclose the name and unit of the reporter.

Article 20 Citizens, legal persons or other organizations that commit fraud in the process of participating in medical insurance, paying medical insurance premiums, and enjoying medical insurance treatment shall be prescribed by the social insurance administrative department in accordance with the relevant laws and regulations of the People s Republic of China Social Insurance Law, Deal with it according to law.

The parties have the right to make statements and defenses, and enjoy the right to apply for administrative reconsideration or file an administrative lawsuit in accordance with the law.

Article 21 A medical insurance service institution that has been deprived of designated qualifications for fraudulent acts shall be notified to the public by the social insurance administrative department.

Article 22 Medical insurance anti-fraud staff members who abuse their powers, neglect their duties, and engage in malpractices for personal gain in medical insurance anti-fraud work shall be dealt with by the supervisory authority according to law; if a crime is constituted, criminal liability shall be investigated according to law. ^[1]

Article 23: Anti-fraud and confiscation income of medical insurance shall be timely and fully paid into the treasury at the same level and included in the budget management.

Medical insurance anti-fraud work funds and reporting reward funds shall be arranged by the same level of finance from anti-fraud fines and confiscated income through departmental budgets based on the development of anti-fraud work.

Article 24 The anti-fraud management of medical expenses for work injury insurance and maternity insurance shall be implemented with reference to these Measures.

Article 25 These Measures shall be implemented as of May 10, 2014. ^[1]