Ping An focuses on the fact that the procuratorial organs have lawfully supervised and safeguarded the 'life-saving money' of the people! ”Recently, when the court overturned the erroneous judgment in the original trial, the staff of Tongcheng County Medical Security Bureau in Hubei Province said with relief. Originally, the private hospital involved in the case repeatedly violated regulations after opening medical insurance settlement in 2020. In 2023, the hospital sued the medical insurance center during its closure period to restore its medical insurance eligibility, which was supported by the first instance court. Last August, the People's Procuratorate of Tongcheng County discovered clues in the case during special supervision. After investigation, it was confirmed that the private hospital involved in the case had serious problems such as insurance fraud and unlicensed operation. It was deemed that the original judgment violated legal provisions, and a recommendation for retrial was issued to the court. In April of this year, the court retried and revoked the original verdict. The procuratorial organs also promoted the joint investigation of the county medical insurance bureau and the health bureau, terminated the medical insurance agreements of 11 problematic institutions, and recovered more than 300000 yuan of illegal medical insurance funds. The medical insurance fund is the "life-saving money" of the people. In practice, procuratorial organs in various regions fully play the dual roles of "supervisors" and "promoters", crack down on and control medical insurance fraud crimes, cooperate with relevant departments to build a secure defense line for medical insurance funds, and ensure that the Party's policies benefiting the people are in the hearts of the people, continuously strengthening the Party's governance foundation. Recently, a lost medical insurance fund was successfully recovered to the medical insurance fund special account under the legal supervision of the Kaizhou District People's Procuratorate in Chongqing. In June 2024, the prosecutor of the court found doubts in the Li work-related injury compensation case during the screening of administrative defeat cases: he admitted to the hospital and claimed to have "accidentally fallen into a river ditch", while the traffic accident determination certificate confirmed that the third party was fully responsible. After investigation, on the evening of February 28, 2020, Li, an employee of a professional cooperative in Kaizhou District, took his colleague's electric tricycle home after work. On the way, a worker mishandled the vehicle, causing it to lose control. Li fell and was urgently sent to the hospital for treatment, which was later recognized as a work-related injury. However, when Li was discharged from the hospital, the medical insurance fund paid him more than 15000 yuan in medical expenses. Since it has been determined that the third party is fully responsible for the traffic accident, the medical expenses should be borne by the third party. However, Li claimed in his admission record that he accidentally fell into a river ditch while walking, completely concealing the fact of the traffic accident, which led the medical insurance department to mistakenly believe that it was an ordinary accident and pay the medical expenses that should have been borne by his colleagues. ”Prosecutor Zhang Fang introduced that it was this false statement that caused Li's husband Zhang to mislead the staff and defraud the medical insurance fund when handling medical expense settlement. In August 2024, the procuratorate issued prosecutorial recommendations to the district medical insurance bureau to urge the recovery of funds and strengthen supervision. Due to the refusal of Mr. and Mrs. Li to cooperate, the clues were transferred to the public security organs for filing. In April of this year, Mr. and Mrs. Li fully refunded their medical insurance premiums. Given that the circumstances of the case are relatively minor and the stolen goods have been returned, the procuratorial organ has made a non prosecution decision in accordance with the law and will no longer propose administrative penalty opinions. The case has been concluded for review. In January last year, the Health Commission of Tongxu County, Henan Province, discovered during a cross examination that a hospital in Qixian had abnormal medication use from 2019 to 2021, with some patients using far more than the standard daily dosage. The clues were then handed over to the public security organs. After the Tongxu County Public Security Bureau filed a case for investigation, the suspect Shi and others were arrested. In November 2024, the public security organs transferred Shi to the People's Procuratorate of Tongxu County for examination and prosecution on suspicion of fraud. After careful verification by the procuratorial organs, comparing drug procurement, inventory and medical insurance system data, and verifying handwritten prescriptions and system input content, it was finally found that Shi committed insurance fraud through the "two accounts" method during the hospital management period. The actual medication used was 19592 units of drugs with a specification of 1.2 grams per unit, while 78368 units of drugs with a specification of 0.3 grams per unit that were not purchased by the hospital were intentionally recorded in the medical insurance system, defrauding the medical insurance fund of nearly 238000 yuan. On February 10th, the Tongxu County Procuratorate prosecuted Shi on suspicion of fraud. Considering that Shi had the initiative to surrender, returned the stolen goods and compensation, and obtained forgiveness, combined with his criminal facts, circumstances, and degree of social harm, a recommendation for determining the sentence was made in accordance with the law. This money can be recovered thanks to the prosecution, and this case has also sounded the alarm for all medical institutions. Don't have any plans for the medical insurance fund. ”After receiving all the defrauded medical insurance fund funds refunded by Mr. Shi, the relevant person in charge of Qixian Social Medical Insurance Center stated. The "data empowerment" big data legal supervision model provides us with an "acceleration" for carrying out the rectification of medical insurance reimbursement violations. At present, most of the medical insurance funds involved in illegal reimbursement of medical expenses in civil cases in the city have been recovered. The linkage mechanism established by the procuratorial organs, courts, and medical insurance bureaus is operating well, and more than 130000 yuan in losses have been recovered in accordance with the law. ”Recently, Li Jing, Director of the Civil Prosecution Department of the People's Procuratorate of Anyang City, Henan Province, introduced that. At the beginning of 2023, prosecutors from Anyang Procuratorate found that in some cases, the infringing party had already borne the medical expenses, but the parties were still reimbursed through medical insurance. Faced with massive medical insurance reimbursement records and civil judgments, manual screening is like searching for a needle in a haystack. How to solve this difficult problem? The procuratorial organs have decided to leverage big data. The Procuratorate of Anyang City, through its independently developed "Legal Supervision Model for Illegal Reimbursement of Medical Insurance Funds", quickly identified suspicious clues by comparing the city's medical insurance reimbursement records from the past three years with the court's civil judgment database. After verification, these cases involved a total of 1.28 million yuan of medical insurance funds that were illegally paid. With the active cooperation of Anyang Medical Security Bureau, the first batch of recovery work has been completed. In 2024, prosecutors continued to use big data legal supervision models for screening and discovered 25 case clues throughout the city. Subsequently, the court simultaneously transferred the case clues to the city's medical insurance bureau. In September 2024, the Anyang Procuratorate issued a prosecutorial recommendation to the city's medical insurance bureau, urging them to take recovery measures in accordance with the law for the transferred case clues, standardize the prevention mechanism, and establish a linkage work mechanism. At the same time, the Procuratorate of Anyang City, together with the Municipal Court and Medical Insurance Bureau, has established a city wide supervision mechanism for handling civil litigation cases related to medical insurance fund reimbursement, improved the management system for third-party reimbursement related to medical insurance funds, and worked together to crack down on illegal and criminal activities related to medical insurance. We will confirm the cause of the injury and keep relevant records when receiving patients with accidental injuries through collaborative supervision. ”Recently, when a prosecutor from Jiayu County People's Procuratorate in Hubei Province was inquiring about the management of medical insurance funds at a designated medical institution, a doctor introduced to the prosecutor that "the hospital also conducts data matching and comparison with the public security organs, and now the phenomenon of false reporting and concealment has been greatly reduced." The above change originated from a case of defrauding medical insurance reimbursement handled by Jiayu County Procuratorate. In August 2023, Ye was injured due to a dispute with someone else. During medical treatment, he falsely claimed to have "fallen" and claimed a medical insurance reimbursement of 7037.28 yuan, but in reality, he had already received compensation of 60000 yuan from the injured person. In October 2024, Ye surrendered and was transferred to the Jiayu County Procuratorate for examination and prosecution on suspicion of fraud. During the investigation, the prosecutor found that the case exposed loopholes in the review and management of medical insurance funds. On May 14th, the hospital issued a prosecutorial recommendation to the medical insurance department, suggesting that it improve the medical insurance review process, establish a cross departmental information sharing mechanism, build a collaborative supervision system, and strengthen legal publicity. After receiving the suggestion from the prosecutor, the medical insurance department attached great importance to it and, after research, introduced multiple rectification measures: strengthening the responsibility of first visit doctors in designated medical institutions to verify the cause of accidental injuries, and establishing the first "firewall" for verifying the cause of accidental injuries; Collaborate with public security, health, human resources and social security, medical institutions, insurance companies, etc. to create a "1+N" three-dimensional regulatory system, promote the construction of inter departmental information exchange and resource sharing mechanisms, and comprehensively enhance the regulatory efficiency of medical insurance funds. In recent years, the deliberate concealment of third-party liability to defraud medical insurance funds has not only eroded the security of the funds, but also led to inconsistent law enforcement and judicial standards due to the vague definition of key issues such as the scope of third-party liability and the determination of concealment behavior. In order to facilitate the two-way connection between administrative law enforcement and criminal justice, the People's Procuratorate of Nong'an County, Jilin Province recently led the signing of a cooperation mechanism for medical insurance fraud governance. During the event, the Nong'an County Procuratorate, together with the County Public Security Bureau, County Court, County Medical Security Bureau, and County Human Resources and Social Security Bureau, jointly signed a case handling guide on medical insurance fraud cases, accurately defining the scope of third-party liability and the criteria for identifying concealment behavior. In response to common situations such as traffic accidents, work-related injuries, and third-party infringement, the scope of third-party liability has been clarified, including the compensation obligations that infringers, employers, or insurance companies need to bear; At the same time, the identification of concealment behavior is refined as the requirement for evidence that insured persons or medical institutions intentionally fabricate 'no third-party liability' to defraud reimbursement. ”The relevant person in charge of the Nongan County Procuratorate stated that the five departments, through quarterly joint meetings and case consultation systems, compare real-time information on traffic accidents, work-related injury claims, etc., to prevent duplicate reimbursements and profit driven law enforcement risks, ensuring that every case can withstand legal scrutiny. (New Society)