National Medical Insurance Bureau： Ten pharmacies were dealt with for illegal use of medical insurance funds, and many of them were chain pharmacies.

CCTV News:On March 30th, the website of the National Health Insurance Bureau exposed 10 typical cases of illegal use of medical insurance funds by designated retail pharmacies. It involves the settlement of medical insurance expenses for non-medical insurance designated retail pharmacies, the exchange of drugs and health care products outside the medical insurance catalogue with drugs in the medical insurance catalogue for settlement, the issuance of false drug purchase documents to cash back the insured, and the inconsistency of drug purchase, sale and storage data. The above-mentioned illegal acts caused the loss of medical insurance fund and harmed the vital interests of the majority of insured people. Designated retail pharmacies should strictly abide by the relevant laws, regulations and rules of medical insurance. The medical security department should crack down on illegal activities such as fraudulent insurance in designated retail pharmacies through daily supervision, on-site inspection, intelligent monitoring and big data analysis in accordance with the law, improve the efficiency of the use of medical insurance funds, and better protect the rights and interests of the majority of insured personnel.

1. Case of illegal use of medical insurance fund by Inner Mongolia Ruichen Pharmaceutical Co., Ltd. in Hohhot, Inner Mongolia Autonomous Region

In August 2021, the Medical Security Bureau of Hohhot City, Inner Mongolia Autonomous Region received a report clue, reflecting that Inner Mongolia Ruichen Pharmaceutical Co., Ltd. was suspected of illegally using the medical insurance fund. By collecting the sales records from January to July, 2021 and the data uploaded by the medical insurance system, the inspectors found that some drugs (such as Erding Granules, Huangqijing Granules, Shiquan Dabu Ointment, Qihu Hawthorn Granules, etc.) in the pharmacy were inconsistent in purchase, sale and storage, and the medical insurance fund was overcharged by 23,004.50 yuan. According to the "Regulations on the Supervision and Administration of the Use of Medical Insurance Funds", the results of the local medical insurance department are as follows: 1. Recover the medical insurance funds illegally used by the pharmacy and impose a fine of 2 times the illegal amount; 2. Interview the person in charge of the pharmacy and order it to be rectified within a time limit, and make irregular return visits to check the rectification of the pharmacy to ensure that the rectification is implemented. At present, the lost medical insurance fund of 23,004.50 yuan has been fully recovered, and the administrative fine of 46,009.00 yuan has been fully paid.

2. The case of illegal use of medical insurance fund by Tiedong Branch of Chengxin Yonghong Pharmacy Chain Co., Ltd. in Siping City, Jilin Province

In February, 2021, the Medical Insurance Bureau of Siping City, Jilin Province received the "Audit Transfer Handling Letter of the Audit Office of Jilin Province on the Issue of Taking Medical Insurance Fund from Tiedong Branch of Siping Chengxin Yonghong Pharmacy Chain Co., Ltd.", and the Siping Medical Insurance Bureau and Siping Audit Bureau formed a joint investigation team to seriously investigate and verify the situation reflected in the transfer handling letter. After investigation, there were some problems in the pharmacy, such as the untimely maintenance of drugs in the medical insurance catalogue and the replacement of drugs outside the medical insurance catalogue with drugs in the catalogue, resulting in the loss of medical insurance fund of 147,044.32 yuan. According to the Service Agreement of Designated Drugstore of Jilin Province’s Basic Medical Insurance in 2020, the local medical insurance department handled the following results: 1. Recover the loss of medical insurance fund caused by the pharmacy, refuse to pay all the deposit and reserve fund of the pharmacy of 882,343.09 yuan, and refuse to pay all the unsettled medical insurance fund of 794,973.05 yuan; 2. Dissolve the medical insurance service agreement of the pharmacy, and you may not apply for medical insurance within three years. At present, the lost medical insurance fund of 147,044.32 yuan has been fully recovered.

3. The case of illegal use of medical insurance fund by Huolong Store of Nantong Jianghai Pharmacy Chain Co., Ltd., Nantong City, Jiangsu Province

In March 2022, the Medical Security Bureau of Haimen District, Nantong City, Jiangsu Province discovered through remote video surveillance that there was a violation of the rules of drug exchange in the Cargo Long Store of Nantong Jianghai Pharmacy Chain Co., Ltd. Upon verification, the Cargo Long Store of Nantong Jianghai Pharmacy Chain Co., Ltd. has empty medical insurance cards to withdraw cash, swiping medical insurance cards for non-designated pharmacies, dispensing medicines with people’s certificates and other acts in violation of medical insurance regulations, involving the illegal use of medical insurance funds of 13,564.58 yuan. According to the Service Agreement of Nantong Basic Medical Insurance Designated Retail Pharmacy, the local medical insurance department handled the following results: 1. Recover the medical insurance fund illegally used by the pharmacy of 13,564.58 yuan, and deduct the penalty of 35,000.00 yuan; 2. Dissolve the medical insurance service agreement of the pharmacy, and you may not apply for medical insurance within three years; 3. Deduct 40 points from the institutional credit score of the pharmacy in 2022. At present, the lost medical insurance fund of 13,564.58 yuan and the liquidated damages of 35,000.00 yuan have all been recovered.

4. The case of illegal use of medical insurance fund by Shengde Pharmacy in Xinyu City, Jiangxi Province

In March, 2022, Xinyu Medical Security Bureau of Jiangxi Province and the Municipal Market Supervision Administration conducted an on-site inspection of the use of medical insurance funds by 30 designated retail pharmacies in the city from January, 2020 to November, 2021, and found that Xinyu Shengde Pharmacy was suspected of illegally using medical insurance funds. After verification, the pharmacy has the following violations: (1) brushing medical insurance cards for non-medical insurance designated pharmacies; Incorporate Chinese herbal pieces that cannot be paid by single taste into the medical insurance fund for settlement; The actual sales quantity of some drugs is less than the medical insurance bookkeeping quantity; Swap drugs and health care products outside the medical insurance catalogue into drugs in the medical insurance catalogue for settlement; Illegal settlement is limited to illegal activities such as the use of drugs for work-related injuries. The above acts involved illegal use of the medical insurance fund of 47,570.40 yuan. According to the Regulations on the Supervision and Administration of the Use of Medical Insurance Funds, the Detailed Rules for the Implementation of the Administrative Punishment Discretion in the Supervision of Medical Insurance Funds in Jiangxi Province (for Trial Implementation) and the Service Agreement of Designated Retail Drugstore of Medical Insurance in Xinyu City, the results of the local medical insurance department are as follows: 1. Recover the medical insurance funds illegally used by the pharmacy; 2. An administrative fine of 100,306.35 yuan was imposed on the pharmacy for defrauding the medical insurance fund of 22,290.30 yuan, and an administrative fine of 45,504.18 yuan was imposed on other general violations of 25,280.10 yuan, totaling 145,810.53 yuan; 3. Dissolve the designated service agreement of medical insurance in this pharmacy, and no longer accept its designated application for medical insurance within three years from the date of issuing the document. At present, the lost medical insurance fund of 47,570.40 yuan has been fully recovered.The administrative fine of 145,810.53 yuan has been paid in full.

V. Case of illegal use of medical insurance fund by Jishou Renmin North Road Branch of Yifeng Pharmacy Chain Co., Ltd. in Xiangxi, Hunan Province

In 2021, Hunan Xiangxi Medical Insurance Bureau found in daily inspection that Yifeng Pharmacy Chain Co., Ltd. Jishou Renmin North Road Branch had the problem of illegal drug expense settlement. Through data comparison, the inspectors found that during the period from January 1 to April 30, 2021, some drugs (such as vinegar corydalis yanhusuo, licorice tablets, acacia flowers, etc.) had no sales records and no inventory, but the actual reimbursement amount in the medical insurance system was 76,794.67 yuan. According to the "Regulations on the Supervision and Administration of the Use of Medical Insurance Funds", the local medical insurance department handled the following results: 1. Ordered the pharmacy to return the illegally used medical insurance funds, and imposed a fine of 1 times the loss of the medical insurance funds; 2, ordered the pharmacy rectification within a time limit. At present, the lost medical insurance fund of 76,794.67 yuan has been fully recovered, and the administrative fine of 76,794.67 yuan has been fully paid.

Six, Chongqing Kaizhou District Pharmaceutical Co., Ltd. illegal use of medical insurance fund case.

In December, 2021, during the daily inspection of designated medical institutions, Chongqing Kaizhou District Medical Security Bureau found that four designated retail pharmacies, including Kaizhou Pharmacy Drug Supermarket, Kaizhou Pharmacy Drug Supermarket Jiulong Road No.2 Store, Kaizhou Pharmacy Supermarket Zhaojiadian and Kaizhou Pharmacy Drug Supermarket Ankang Street Store, were suspected of taking employee medical insurance personal account funds for the insured. After investigation, four designated retail pharmacies under Chongqing Kaizhou Pharmaceutical Co., Ltd. took advantage of their units to purchase epidemic prevention materials, used their employees’ personal medical insurance accounts for settlement, and then issued tax bills in the name of their units and returned them to their units for reimbursement. There were irregularities in taking employees’ personal medical insurance account funds, involving the amount of employees’ personal medical insurance accounts of 14,869.90 yuan. According to the "Regulations on the Supervision and Administration of the Use of Medical Insurance Funds", the local medical insurance department handled the results as follows: 1. Ordered the four designated retail pharmacies involved in the case to return the medical insurance funds illegally used, and imposed a fine of 1 times the illegal amount; 2. Order the company to strengthen the publicity of medical insurance policies, conduct self-examination and rectification on the relevant problems existing in this inspection, and form a written report; 3. Five insured persons involved in the case did not understand the policy of medical insurance fund, so they gave warning education. At present, the lost medical insurance fund of 14,869.90 yuan has been fully recovered, and the administrative fine of 14,869.90 yuan has been fully paid.

7. The case of illegal use of medical insurance fund by people’s pharmacy in Haicheng District, Beihai City, Guangxi Zhuang Autonomous Region.

In February 2021, the Medical Security Bureau of Beihai City, Guangxi Zhuang Autonomous Region received a report clue, reflecting that the people’s pharmacy in Haicheng District of Beihai City was suspected of illegally using the medical insurance fund. After investigation, the pharmacy has forged false vouchers to exchange cash, placed illegal items and other violations, involving the illegal use of medical insurance funds of 71,847.05 yuan. According to the Service Agreement of Designated Retail Pharmacy for Employees’ Basic Medical Insurance in Beihai City (Monomer in 2020) and other relevant regulations, the results of the local medical insurance department are as follows: 1. Deduct the medical insurance fee of 71,847.05 yuan in the month when the pharmacy violated the regulations, and announce the violations of the pharmacy to the public; 2. Cancel the designated service agreement of medical insurance in this pharmacy, and no longer accept its designated application for medical insurance within three years. At present, the illegal use of medical insurance funds of 71,847.05 yuan has been fully recovered.

8. The case of illegal use of medical insurance fund by Wuhaotang Pharmacy in duyun city, Qiannan Prefecture, Guizhou Province.

In September, 2021, duyun city Medical Security Bureau in Qiannan Prefecture, Guizhou Province, found that Wuhaotang Pharmacy in duyun city was suspected of using medical insurance funds in violation of regulations. Investigators from duyun city Medical Insurance Bureau in Qiannan Prefecture found that there were many abnormal cases of large medical insurance card settlement in this pharmacy. Investigate and verify suspicious clues by collecting the data of pharmacy sales system, interviewing the person in charge of relevant designated retail pharmacies, and returning to the insured by telephone. After verification, the pharmacy provided medical insurance settlement for medical expenses incurred by five people, including Xiong Moumou, who was treated in a dental clinic in Duyun, involving a medical insurance fund totaling 41,880.00 yuan. According to the Service Agreement of Designated Retail Drugstore for Medical Security in Qiannan Prefecture and the Implementation Plan of duyun city on Carrying out Medical Insurance Credit Rating of Designated Medical Institutions, the local medical insurance department handled the results as follows: 1. Deducting the pharmacy’s illegal use of medical insurance fund of 41,880.00 yuan, and paying 2.5 times of liquidated damages, with the total deduction and liquidated damages of 146,580.00 yuan, which have all been returned to the medical insurance fund account; 2. From November 2, 2021, the medical insurance service agreement of this pharmacy will be dissolved and its violation will be announced to the public, and it will be included in the blacklist management of medical insurance credit rating; 3. Incorporate the legal representative and pharmacy manager of the pharmacy into the list of medical insurance untrustworthy persons; 4. Transfer the violation of the dental clinic involved to the local health department for handling.

9. The case of illegal use of medical insurance fund by Hongyan Pharmacy in Shannan City, Xizang Autonomous Region

In April, 2022, the Medical Security Bureau of Shannan City, Xizang Autonomous Region found that there was a phenomenon of "one person swiping cards continuously" in Hongyan Pharmacy in Shannan City. In June, 2022, Shannan Medical Insurance Bureau initiated an investigation into the illegal settlement of medical insurance fund by Hongyan Pharmacy. After investigation, Hongyan Pharmacy has fraudulent behaviors of swindling medicines and fictitious medical services, swindling the purchase of local products, health care products and other consumer goods into medicines and swiping medical insurance vouchers for settlement, and at the same time, there are illegal behaviors such as medical insurance vouchers for insured persons staying in the store and swiping cards regularly every day, involving medical insurance funds totaling 102,625.00 yuan. According to "People’s Republic of China (PRC) Social Insurance Law" and "Regulations on the Supervision and Administration of the Use of Medical Insurance Funds", the results of the local medical insurance department are as follows: 1. Order the pharmacy to return the defrauded medical insurance fund and impose a fine of 205,250.00 yuan twice the amount defrauded; 2. Suspend the medical services used by the medical insurance fund in this pharmacy for 6 months. At present, the lost medical insurance fund of 102,625.00 yuan has been fully recovered, and the twice administrative fine of 205,250.00 yuan has been fully paid.

X. Case of illegal use of medical insurance fund in a branch of Tiancheng Pharmacy, Karamay City, Xinjiang Uygur Autonomous Region

In July 2022, the Medical Security Bureau of Karamay City, Xinjiang Uygur Autonomous Region received a report clue, reflecting that a branch of Tiancheng Pharmacy in Karamay City was suspected of illegally using medical insurance funds. Verified by the Medical Insurance Bureau of Karamay District, Karamay City, the pharmacy has illegal behaviors such as swapping drugs, issuing false drug purchase documents to provide cash back for insured persons, involving illegal use of medical insurance funds of 155,775.69 yuan. According to the "Regulations on the Supervision and Administration of the Use of Medical Insurance Funds", the results of the local medical insurance department are as follows: 1. Recover the medical insurance funds illegally used by the pharmacy and impose a fine of 2 times the illegal amount; 2, ordered the pharmacy rectification within a time limit. At present, the lost medical insurance fund of 155,775.69 yuan has been fully recovered, and the administrative fine of 311,551.38 yuan has been fully paid.