How to defraud medical insurance?

The conviction standard of medical insurance fraud is:

1. The insured lends his social security card to others or units for use.

2. The insured person purchases a large number of drugs unrelated to his disease through abnormal medical treatment and drug purchase behaviors such as medical insurance.

3. The insured defrauds the reimbursement funds by means of impersonation or medical treatment.

4. The insured defrauds reimbursement funds by forging or altering medical records, prescriptions, illness certificates, receipts and other means.

5. The insured defrauds reimbursement funds by changing hands or reselling drugs.

6. The insured person submits untrue medical information, etc.

7. The insured refuses to accept the investigation and inspection after receiving the notice of medical insurance inspection.

The basic medical insurance fund shall, in principle, implement municipal co-ordination. The basic medical insurance covers all employers and their employees in cities and towns; All enterprises, state administrative organs, institutions and other units and their employees must fulfill the obligation to pay the basic medical insurance premium. The employer's contribution ratio is about 6% of the total salary, and the individual contribution ratio is 2% of my salary. Part of the basic medical insurance premium paid by the unit is used to establish the overall fund, and part of it is included in the personal account; The basic medical insurance premiums paid by individuals are included in personal accounts. Pooling funds and individual accounts bear different responsibilities for payment of medical expenses. The overall fund is mainly used to pay for the hospitalization and outpatient treatment of some chronic diseases, and the overall fund has a minimum payment standard and a maximum payment limit; Personal accounts are mainly used to pay for general outpatient expenses.

In order to ensure that the insured employees enjoy basic medical services and effectively control the excessive growth of medical expenses, the China Municipal Government has strengthened the management of medical services, formulated the basic medical insurance drug list, diagnosis and treatment items and medical service facilities standards, provided qualified medical institutions and pharmacies with basic medical insurance services, and allowed the insured employees to choose independently. In line with the reform of the basic medical insurance system, the state has also promoted the reform of medical institutions and drug production and circulation systems. By establishing the competition mechanism between medical institutions and the market operation mechanism of drug production and circulation, we will strive to achieve the goal of "providing better medical services at lower cost".

Legal basis:

People's Republic of China (PRC) social insurance law

Article 87 Where social insurance agencies, medical institutions, pharmaceutical trading entities and other social insurance service institutions defraud social insurance fund expenditures by means of fraud or forgery of certification materials, the social insurance administrative department shall order them to return the defrauded social insurance money and impose a fine of more than 2 times but less than 5 times the amount defrauded; If it belongs to a social insurance service institution, the service agreement shall be terminated; If the directly responsible person in charge and other directly responsible personnel are qualified, their qualifications shall be revoked according to law.

Article 88 Anyone who defrauds social insurance benefits by fraud, forgery of certification materials or other means shall be ordered by the social insurance administrative department to return the defrauded social insurance benefits, and shall be fined at least two times but not more than five times the amount defrauded.