First, the concept of medical insurance Medical insurance generally refers to social medical insurance, which is a social security system created to compensate employees for property losses caused by disease risks. After employers, companies and individuals pay fees, medical insurance funds will be established. After the insured person falls ill and goes to the hospital for medical expenses, medical insurance institutions will give certain economic compensation.
The establishment and implementation of the social medical insurance system has gathered the economic strength of units and social groups. With the support of relevant departments, sick social groups can get necessary material supply assistance from individuals, reduce the pressure of medical expenses, and avoid the "poverty caused by illness" of sick social groups.
Second, what allows or induces people who do not pay social security to be hospitalized in the name of the insured? The self-funded part shall be subject to the payment of social security, and the self-funded medical expenses shall be applied for by the medical insurance fund. Hanging a bed in hospital can also pay outpatient social security. If I choose to pay social security, I will make repeated appointments and register, repeat or unconditionally treat, resolve over-medical treatment in the form of hospitalization or provide unnecessary health services. In violation of the medical insurance drug category or drug category requirements, excessive and repeated use of drugs, illegal use of drugs with special restrictions, or preparation of liquid for social security payers in the form of dissolution or prescription change. The expenses incurred by non-designated hospitals are merged into designated hospitals for medical insurance, and settled with medical insurance and social security agencies. Help pay social security, and defraud personal accounts, stock funds or overall funds of medical insurance.
Without authorization, raise the tariff standard, raise the project fee, dissolve the fee standard, repeat the fee, and constantly expand the fee standard. Engaging in malpractices for selfish ends, defrauding medical insurance funds or personal account funds in the form of false reports or false data and information. Selling drugs for non-designated drug trading enterprises and swiping social security cards on their behalf. Changing the expenses of drugs, diagnosis and treatment items, medical materials, diagnosis and treatment service facilities or daily necessities, health food and other expenses beyond the scope of medical insurance payment into expenses within the scope of medical insurance policy, applying for medical insurance liquidation, and defrauding the medical insurance fund to pay.
Forging or using false medical records, prescriptions, inspection and laboratory reports, hospital diagnosis certificates and other medical documents to defraud the medical insurance fund. Apply for reimbursement of false medical expenses documents. Other personal behaviors that violate the relevant provisions of social security and lead to the loss of medical insurance funds.
Third, evaluate the related illegal and criminal problems involved in the crime of insurance fraud (1) and clarify the boundaries between the crime of insurance fraud and non-crime. The key point is whether the amount of defrauding insurance money is large, which can be solved according to the general violation of insurance law, so that a large amount constitutes the crime of insurance fraud.
(2) Related criminal issues involved in the determination of insurance fraud. Whoever commits insurance fraud activities and intentionally causes economic losses, beneficiary's death, disability and illness by means of arson, beating, damage, spreading infectious diseases, abuse and abandonment, and defrauds the security fund, shall be punished for arson, insurance fraud, homicide, insurance fraud, intentional injury, insurance and other crimes in accordance with the second paragraph of Article 198 of the Criminal Law. The above is insurance fraud.