Original Title: Refining Typical Issues, Clarifying Operational Standards

New Medical Insurance Fund Regulations Draw a Red Line Against Fraud (Policy Interpretation)

The medical insurance fund is the people’s “money for medical treatment” and “lifesaving money.” The security of the medical insurance fund is related to the healthy and sustainable development of the medical security system and the vital interests of the general public. The “Detailed Implementation Rules for the Regulations on the Supervision and Administration of the Use of Medical Security Funds,” which took effect in April, provides detailed provisions on fund use, supervision and administration, and legal responsibilities.

Establishing Executable and Accountable Operational Standards

“The ‘Regulations on the Supervision and Administration of the Use of Medical Security Funds,’ which took effect in May 2021, laid the legal foundation for strengthening the supervision of medical insurance funds. Supervision work has achieved significant results. Medical insurance departments at all levels have recovered approximately 1.2 trillion yuan in medical insurance funds through agreement handling, administrative penalties, and other means. Intelligent supervision has prevented fund losses of 9.5 billion yuan, initially reversing the passive situation of ‘lenient and soft’ supervision of medical insurance funds. However, supervision work still faces some challenges. The rights and responsibilities of various parties need further clarification, the identification of illegal activities needs further refinement, and new situations arising from reforms need further definition.”

Regarding the identification of illegal activities, the subjective intent of “for the purpose of defrauding the medical insurance fund” is difficult to directly obtain evidence for. Concepts such as “refusing to cooperate with investigations” and “inducing others to seek medical treatment or purchase drugs under false identities” require unified evaluation standards and law enforcement scales as much as possible. Recently exposed cases, such as inducing hospitalization and full-chain fraud to obtain maternity allowances, have raised new requirements for identifying illegal activities.

With the deepening of payment method reforms, issues such as the relationship between违规金额 and fund losses, loss identification under DRG (Diagnosis-Related Groups)/DIP (Diagnosis-Intervention Packet) payment, calculation methods, and timing urgently need responses at the legal system level. Some medical institutions engage in “upcoding” disease groups by altering case classifications or inflating diagnostic complexity. How to identify and penalize such situations requires further clarification of the basis beyond existing rules. The regulatory basis for weak areas such as long-term care insurance, maternity allowances, medical assistance, and drug and consumable traceability codes also urgently needs clarification.

“Formulating the detailed implementation rules is to further smooth the ‘last mile’ of medical insurance fund supervision.” The detailed implementation rules transform the framework and principled provisions of the regulations into executable and accountable operational standards, providing a more operable legal system basis for fund supervision work.

Focusing on Combating Issues Like Reselling ‘Recycled Drugs’

Illegal and违规 activities involving medical insurance funds are diverse. Which ones constitute违规 and which are suspected of fraud? The nature differs, determining the severity of penalties. Drawing a red line against fraud is of great significance.

The detailed implementation rules refine typical prominent issues encountered in supervision, providing a more powerful legal weapon for severely cracking down on fraud.

Focus on combating fraud involving methods like “providing transportation, reducing or waiving fees, offering benefits, or giving gifts like rice, flour, and oil.” The rules stipulate that designated medical institutions that induce or guide others to seek medical treatment or purchase drugs under false identities through persuasion, false advertising,违规 fee reductions or waivers, or providing additional property (services) can be identified as committing fraud. Individuals who, knowing that others are committing fraud, still participate in their organized illegal activities and accept gifts, fee reductions/waivers, or additional services can be penalized for fraud.

Focus on combating issues like reselling “recycled drugs.” The detailed rules stipulate that designated medical institutions that organize others to purchase drugs or medical consumables through medical insurance fraud and then illegally acquire and resell them can be identified as committing fraud.

If designated medical institutions and their staff明知 others are seeking medical treatment or purchasing drugs under false identities for the purpose of fraud and still provide assistance, it can be identified as fraud. In supervision, cases have been found where drug dealers went to a hospital with over a dozen medical security certificates to get prescriptions, and medical staff directly cooperated without verifying any identity information or authorization documents. This constitutes “assisting others in seeking medical treatment or purchasing drugs under false identities” and can be identified as fraud.

Regarding professional fraudsters like drug dealers, the detailed rules stipulate that individuals who长期 or多次 acquire and resell medical insurance drugs from/to non-specific交易对象 can be deemed to have the

Regulations on the Supervision and Administration of the Use of Medical Security Funds

This is not a place or cultural site, but a legal document. It is a set of administrative regulations issued by the Chinese government to standardize the management and use of the national healthcare security fund, aiming to ensure its safety and efficiency. These regulations were enacted to prevent fraud and misuse, thereby safeguarding this critical public welfare resource.

Detailed Implementation Rules for the Regulations on the Supervision and Administration of the Use of Medical Security Funds

The “Detailed Implementation Rules for the Regulations on the Supervision and Administration of the Use of Medical Security Funds” is not a place or cultural site. It is a Chinese regulatory document that provides specific operational guidelines for managing and overseeing the country’s public healthcare funds. These rules were established to ensure the proper and lawful use of this critical social security resource, reflecting ongoing efforts to improve and safeguard the national healthcare system.

medical insurance fund

The “medical insurance fund” is not a specific place or cultural site, but a social security system. Its history is rooted in late 19th-century Germany with Bismarck’s social legislation, which established the first compulsory national health insurance to provide workers with financial protection against illness. Today, such funds are foundational to public health systems worldwide, operating as government agencies or regulated non-profit organizations.

medical security system

A medical security system typically refers to a country’s organized framework for providing healthcare access and financial protection to its population, such as national health insurance. Its history is often rooted in 19th and 20th-century social reforms, with Germany’s statutory health insurance (1883) frequently cited as a pioneering model. These systems have evolved globally to address public health, economic stability, and the fundamental right to medical care.

DRG (Diagnosis-Related Groups)

“DRG (Diagnosis-Related Groups)” is not a physical place or cultural site, but a medical and economic classification system. It was developed at Yale University in the 1980s to categorize hospital patients into groups based on their diagnoses and treatments, primarily for standardizing healthcare costs and payments. This system has since been adopted and adapted by many countries’ health systems to manage hospital reimbursement and resource allocation.

DIP (Diagnosis-Intervention Packet)

“DIP (Diagnosis-Intervention Packet)” does not refer to a physical place or cultural site. It is a term used in fields like education or healthcare, typically describing a structured set of tools or procedures for assessment and planning.

Therefore, it does not have a geographical location or a cultural history to summarize in the traditional sense.

long-term care insurance

“Long-term care insurance” is not a physical place or cultural site, but a financial product designed to cover the costs of extended personal care services, such as those needed for chronic illnesses or disabilities. It emerged in the late 20th century, primarily in countries like the United States, as a private-sector response to the rising costs of eldercare and the limitations of public health programs like Medicare. Its history is tied to increasing life expectancy and the growing need for financial planning to manage the high expenses of nursing homes, assisted living, and in-home care.

maternity allowances

“Maternity allowances” are not a specific place or cultural site, but a social welfare policy. Historically, such allowances emerged in the late 19th and early 20th centuries, with early examples in countries like Germany, as part of social insurance systems designed to support mothers and newborns. Today, they are common in many nations as financial benefits provided during pregnancy or after childbirth.