Depending on whether the perpetrator defrauded medical insurance funds by fabricating facts and concealing the truth for the purpose of illegal possession, factors such as the amount involved and the severity of the behavior will all affect the conviction and sentencing.
1. Definition and methods of medical insurance fraud Medical insurance fraud refers to the behavior of actors defrauding medical insurance funds by fabricating medical conditions, forging medical records, fraudulently using other people’s medical insurance cards, etc.
These behaviors not only damage the fairness and sustainability of the medical insurance system, but also infringe on the legitimate rights and interests of the majority of insured persons.
2. Conviction standards for medical insurance fraud The conviction of medical insurance fraud is mainly based on the relevant provisions of the Criminal Law of the People's Republic of China and the People's Republic of China, and the main crimes involved include fraud and insurance fraud.
Specific criteria for conviction include: 1. Whether there is the purpose of illegal possession: the perpetrator must have the purpose of illegal possession, that is, to commit fraud in order to obtain medical insurance funds.
2. Whether methods such as fabricating facts and concealing the truth were used: The perpetrators used methods such as fabricating medical conditions and forging medical records to create misunderstandings in medical insurance institutions, thereby defrauding medical insurance funds.
3. The amount of money involved: The amount of money involved in defrauding medical insurance funds is one of the important factors in conviction and sentencing.
Generally speaking, the greater the amount, the heavier the conviction and sentence.
4. The severity of the behavior: The perpetrator’s fraud methods, frequency, duration and other factors will also affect the conviction and sentencing.
The more serious the circumstances, the heavier the conviction and sentencing.
3. Preventive Measures for Medical Insurance Fraud In order to prevent medical insurance fraud, we need to strengthen the management and supervision of the medical insurance system, improve the medical insurance review mechanism, and improve the professional quality and responsibility of reviewers.
At the same time, it is also necessary to strengthen publicity and education to improve the legal awareness and risk prevention awareness of insured persons.
To sum up: the conviction of medical insurance fraud mainly depends on whether the perpetrator defrauds medical insurance funds by fabricating facts, concealing the truth and other means for the purpose of illegal possession. Factors such as the amount involved and the severity of the behavior will all affect the conviction and sentencing.
In order to prevent medical insurance fraud, we need to strengthen the management and supervision of the medical insurance system, improve the professional quality and sense of responsibility of reviewers, and at the same time strengthen publicity and education to improve the legal awareness and risk prevention awareness of insured persons.
Legal basis: Article 266 of the "Criminal Law of the People's Republic of China" stipulates: Whoever defrauds public or private property, if the amount is relatively large, shall be sentenced to fixed-term imprisonment of not more than three years, criminal detention or surveillance, and shall also or solely be fined; the amount shall be:
If the amount is huge or there are other serious circumstances, he shall be sentenced to fixed-term imprisonment of not less than three years but not more than ten years, and shall also be fined; if the amount is particularly huge or there are other particularly serious circumstances, he shall be sentenced to fixed-term imprisonment of not less than ten years or life imprisonment, and shall also be fined or his property shall be confiscated.
If this law provides otherwise, the provisions shall prevail.
Article 198 of the "Criminal Law of the People's Republic of China" stipulates: Whoever commits insurance fraud activities under any of the following circumstances and the amount is relatively large shall be sentenced to fixed-term imprisonment of not more than five years or criminal detention, and shall also be fined not less than 10,000 yuan
A fine of not more than 100,000 yuan; if the amount is huge or there are other serious circumstances, he shall be sentenced to fixed-term imprisonment of not less than five years but not more than 10 years, and a fine of not less than 20,000 yuan but not more than 200,000 yuan; if the amount is particularly huge or there are other particularly serious circumstances, he shall be sentenced to fixed-term imprisonment of not less than five years but not more than 10 years, and a fine of not less than 20,000 yuan but not more than 200,000 yuan; if the amount is particularly huge or there are other particularly serious circumstances, he shall be sentenced to fixed-term imprisonment of not less than five years but not more than 10 years.
A prison sentence of not less than ten years and a fine of not less than RMB 20,000 but not more than RMB 200,000 or property confiscation: (1) The policy holder intentionally fabricates the insurance subject and defrauds the insurance money; (2) The policy holder, the insured or the beneficiary
Making up false causes of an insured accident or exaggerating the extent of the loss to defraud the insurance money; (3) The policy holder, the insured or the beneficiary fabricating insurance accidents that have not happened and defrauding the insurance money;
The insurer intentionally causes an insured accident to cause property damage and defrauds the insurance money; (5) The policy holder or beneficiary intentionally causes the death, disability or illness of the insured to defraud the insurance money.
If any of the acts listed in items 4 and 5 of the preceding paragraph are committed and constitute other crimes, they shall be punished in accordance with the provisions of concurrent punishment for several crimes.
If a unit commits the crime in Paragraph 1, the unit shall be fined, and the person directly in charge and other directly responsible persons shall be sentenced to fixed-term imprisonment of not more than five years or criminal detention; if the amount is huge or there are other serious circumstances, the unit shall be sentenced to not less than five years and ten years.
A fixed-term imprisonment of not more than 10 years; if the amount is particularly huge or there are other particularly serious circumstances, the offender shall be sentenced to a fixed-term imprisonment of not less than 10 years.
Article 87 of the "Social Insurance Law of the People's Republic of China" stipulates: Social insurance agencies, medical institutions, pharmaceutical business units and other social insurance service agencies defraud social insurance fund expenditures through fraud, forged certification materials or other means.
, the social insurance administrative department shall order the return of the fraudulently obtained social insurance funds, and impose a fine of not less than two times but not more than five times the amount of the fraudulent amount; if it belongs to a social insurance service agency, the service agreement shall be terminated; the directly responsible person in charge and other directly responsible personnel shall have professional qualifications
, his or her professional qualifications shall be revoked in accordance with the law.