Multi-departments coordinate resources, exert joint efforts of supervision, and severely crack down on illegal use of medical insurance funds.
CCTV News:In view of the irregular problems in some retail pharmacies, such as drug swapping and over-prescribing, resulting in the loss of medical insurance funds, the National Medical Insurance Bureau said on June 2 that it would increase supervision over designated retail pharmacies, urge them to standardize their business practices from the beginning of using the overall fund, at the same time, increase flight inspection, improve the effect of special rectification, and unite multi-departments to coordinate the supervision resources and exert the joint efforts of supervision to severely crack down on fraudulent insurance fraud such as false drug purchase and reselling medical insurance drugs.
From the practice of medical insurance fund supervision, some designated retail pharmacies illegally use medical insurance funds mainly in the following situations:
The first category is false prescription. Making up or forging drug prescriptions or sales records and swiping medical insurance codes (social security cards) without actually purchasing or selling drugs to defraud medical insurance funds.
The second category is drug swapping. Including swapping non-medical drugs for medical insurance drugs, using medical insurance funds to pay for health care products, food, cosmetics, etc., swapping non-medical insurance drugs for medical insurance drugs, and swapping low-priced drugs for high-priced drugs.
The third category is over-prescribing. First, sell the drugs that I don’t need or obviously exceed my consumption demand to the insured through buying gifts, exemption and reduction; Second, it provides convenience for drug distributors (such as sales staff of pharmaceutical companies) to prescribe more expensive drugs and settle medical insurance, so as to resell and promote drugs at low prices; The third is to induce the insured to use the employee medical insurance outpatient co-ordination fund for centralized drug purchase and peak consumption at the end of the year.
The fourth category is to settle medical insurance for other pharmacies. Lend the medical insurance settlement system to non-medical insurance designated retail pharmacies or designated retail pharmacies that have been suspended from medical insurance settlement, and make medical insurance settlement on their behalf.
The fifth category is management problems. For example, prescription drugs are sold without prescription, drugs are sold first and then prescribed, and the records of drug purchase and sale do not match.
Designated retail pharmacies will be punished for illegal use of medical insurance funds.
The National Medical Insurance Bureau said that designated retail pharmacies should implement the main responsibility of self-management, and those who violate relevant regulations will be punished accordingly.
In accordance with the regulations on the supervision and administration of the use of medical insurance funds and other rules, designated retail pharmacies shall not induce or assist others to impersonate or falsely purchase medicines, shall not forge, alter, conceal, alter, destroy medical documents, accounting vouchers, electronic information and other relevant materials, and shall not fabricate medical services. Violation of this requirement is an act of fraudulent insurance, and the medical insurance administrative department will order it to return the losses caused by the medical insurance fund and impose a fine of more than 2 times and less than 5 times the amount defrauded; At the same time, it is ordered to suspend the medical services involved in the use of medical insurance funds by designated medical institutions for more than 6 months and less than 1 year, until the medical insurance agency terminates the service agreement; Those with professional qualifications shall be revoked by the relevant competent departments according to law.
The above acts also constitute a crime of fraud, and the relevant responsible personnel may be imprisoned. Designated medical institutions (including pharmaceutical business units) for the purpose of illegal possession, defrauding medical insurance fund expenditures, the organization, planning, implementation of personnel, convicted and punished for fraud; If it constitutes other crimes at the same time, it shall be convicted and punished in accordance with the provisions of heavier punishment. Those who knowingly illegally purchase and sell drugs purchased by using medical insurance to defraud are convicted and punished for concealing and concealing the crime; Instigating, instigating and instructing others to use medical insurance to defraud and buy drugs, and then illegally buying and selling them, they are convicted and punished for fraud.