The medical security fund is the people's "medical money" and "life-saving money", but there are many cases of waste caused by excessive drug purchases and reselling drugs to obtain medical insurance funds. Recently, the Yulin Medical Insurance Bureau of Shaanxi Province successfully cracked a medical insurance fraud case involving "reflux drugs", which aroused widespread concern in the society.
The insured person purchases a 15-year supply within three months
The police intervened in the investigation and cracked the "reflux drug" case
The staff of the Medical Insurance Bureau of Yulin City, Shaanxi Province, found during the daily inspection that Chang Mou, an insured person with a chronic disease, had purchased enough therapeutic drugs for 15 years in just three months. This unusual behavior immediately alerted the Health Insurance Bureau.
After investigation, it was found that Chang suffered from chronic renal failure and other diseases, and according to the chronic disease medical insurance reimbursement policy, Chang's usual medication medical insurance reimbursement reached 85%. This made Chang see an opportunity, and he resold the extra drugs to drug dealers at a low price, and the drug dealers then flowed the drugs to the market, forming an illegal chain of interests.
However, cases like Chang's are not unique. Through the investigation and investigation of medical insurance fraud cases, the police found that:
- Criminals use over-dispensing and re-dispensing to obtain drugs and resell them to drug dealers.
- Drug dealers collect and sell at a low price through the Internet to earn the difference.
This kind of behavior of selling "reflux drugs" has led to the people's medical insurance fund, which should be used to save lives, being eaten by lawbreakers.
The National Health Insurance Bureau has established a "traceability code" payment supervision system
Eliminate "over-purchased" from the source
In order to eliminate the phenomenon of "over-purchase" from the source, the National Health Insurance Administration has promoted the sharing of drug and medical insurance settlement information and carried out a nationwide big data supervision pilot. Yulin City, Shaanxi Province, as a pilot city, promotes the application of the "traceability code" of medical insurance drugs in outpatient co-ordination and designated pharmacies.
This innovative regulatory measure, by realizing the integration of the traceability code and the commodity code, and the mandatory scanning of the code in the drug settlement and medical insurance payment links, effectively grasps the key information such as the prescribing institution, the number of drugs purchased, and the drug purchase cycle.
According to the pharmacy sales staff, the system will give an alarm in real time if the insured buys drugs in advance or in excess of any pharmacy in Yulin City.
As of June 10, the "traceability code" control system of 81 chronic disease pharmacies in Yulin City had compared a total of 2.03 million pieces of data, intercepted 14,057 repayments for the same drug, and involved a cost of up to 1.2629 million yuan.
It is reported that the National Health Insurance Administration is actively exploring the development of the "reselling medical insurance drugs" big data supervision model, improving the intelligent reminder function of the medical insurance intelligent monitoring system, and putting an end to the phenomenon of repeated drug prescribing between different hospitals and reselling drugs for profit. At present, nearly half of the provinces in the country have started the work of reminding abnormal drug prescribing, and Beijing, Tianjin, Ningxia and other places have basically achieved full coverage.
Medication safety should not be overlooked
Directly or indirectly assisting in the sale of "reflux drugs" is involved in insurance fraud
The existence of "reflux drugs" not only disrupts the order of the drug market, but also poses a serious threat to drug safety.
The "reflux drugs" purchased by drug dealers include a large number of high-priced anti-cancer drugs, targeted drugs, etc. Certain pharmaceutical products, such as insulin and live bifidobacteria capsules, require specific storage conditions, and if the storage conditions are not met, the quality and effectiveness of the drug will be affected.
According to the National Health Insurance Administration, some drug dealers may fill fake drugs in real medicine boxes or put expired drugs into new medicine boxes. Patients only see the new date on the pill box, but they don't know that they may be taking expired medicine.
The National Health Insurance Administration has made it clear that the direct or indirect auxiliary sales of "reflux drugs" are suspected of fraud and insurance fraud.
In February this year, the Supreme People's Court, the Supreme People's Procuratorate, and the Ministry of Public Security jointly issued the "Guiding Opinions on Several Issues Concerning the Handling of Criminal Cases of Medical Insurance Fraud", which clearly pointed out:
- Illegally purchasing or selling drugs that are clearly known to be purchased through medical insurance fraud, and convicted and punished for the crime of covering up or concealing criminal proceeds;
- Instigating, instigating, or instigating others to use medical insurance to fraudulently purchase drugs, and then illegally purchase or sell them, is to be convicted and punished as the crime of fraud;
- The insured person may face the penalty of not being able to use the medical insurance if he or she resells the drug, and even the crime of fraud.
Yang Ling, director of the second supervision division of the Fund Supervision Department of the National Medical Security Administration, pointed out that individuals who use medical insurance benefits to defraud the medical security fund, resell drugs or make illegal profits will face a 3 to 12-month suspension of medical insurance network settlement, and be fined 2 to 5 times the amount of fraudulent insurance, which may constitute the crime of fraud if the circumstances are serious.
A few days ago, the National Health Insurance Administration, the Supreme People's Court, the Ministry of Public Security, the National Health Commission and other six departments jointly deployed the special rectification of violations of laws and regulations in the medical insurance fund. If the public finds similar behavior, they can call the National Health Insurance Bureau's anti-fraud and insurance fraud reporting hotline, or report to the local medical insurance department, and the medical insurance department will give a reward of up to 200,000 yuan depending on the report.
The National Health Insurance Administration reminds that the insured should be vigilant, do not buy drugs from unknown sources and damaged packaging, and do not turn the "life-saving drugs" in their hands into a "cash cow" for drug dealers.
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