Measures of Shanghai Municipality on Supervision and Administration of Basic Medical Insurance. Individuals who, in violation of medical insurance regulations, fraudulently use other people's basic medical insurance vouchers or forge or alter basic medical insurance vouchers to settle the basic medical insurance expenses, the Municipal People's Insurance Bureau will order them to return the basic medical insurance expenses paid by the medical insurance fund, and may also impose a warning or a fine of more than 2, yuan in 1 yuan. If the circumstances are serious, a fine of more than 2, yuan and less than 1, yuan will be imposed, and the accounting and settlement method of basic medical insurance expenses can be changed for 1 to 6 months. The Measures shall come into force as of May 1st.

The "Measures" published yesterday also include four other penalties for individuals who violate medical insurance regulations, including lending their basic medical insurance vouchers to others for use, or settling basic medical insurance expenses through paid transfer of medical treatment vouchers and settlement documents; Through repeated visits or forged, altered, altered medical history, prescriptions, reimbursement vouchers, medical expense documents, etc., the basic medical insurance expenses are settled; Selling drugs settled by basic medical insurance expenses; Take other ways to damage the medical insurance fund and settle the basic medical insurance expenses, which can also be punished according to the above provisions.

the original "Shanghai basic medical insurance measures for urban workers" stipulates that if the number of medical visits or medical expenses incurred by insured persons in outpatient and emergency departments obviously exceeds the normal situation, they can take measures to change the accounting and settlement method of outpatient and emergency medical expenses, that is, the original online "swipe card" accounting and settlement of outpatient and emergency medical expenses will be changed to cash settlement with designated medical institutions, and then they will apply for reimbursement at the designated district and county medical insurance center with medical insurance and other relevant information. The implementation of this measure has played a positive role in maintaining the security of medical insurance funds. However, the frequency of medical treatment in outpatient and emergency departments or the medical expenses incurred obviously exceed the normal situation, and there are many reasons such as specific illness.

therefore, the "measures" published yesterday stipulate that if measures are taken to temporarily change the accounting and settlement methods of basic medical insurance expenses for outpatient and emergency departments, the municipal medical insurance supervision and inspection office shall notify the insured and timely review their medical treatment. If no irregularities are found after the audit, the accounting and settlement method of the basic medical insurance expenses for outpatient and emergency departments shall be restored on the day when the audit is completed.

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Provisions on penalties for violation of regulations of designated medical institutions and retail pharmacies

Anyone who commits any of the following acts will be ordered to make corrections, recover the medical insurance expenses paid by the medical insurance fund, and may be punished with a warning or a fine ranging from 3, yuan to 1, yuan; If the circumstances are serious, the basic medical insurance settlement relationship can be suspended for one to six months or the qualification of the designated basic medical insurance can be cancelled:

(1) failing to verify the basic medical insurance certificate in accordance with the regulations and settling the basic medical insurance expenses for individuals who use the basic medical insurance certificate for medical treatment or dispensing drugs in violation of regulations;

(2) making up medical services or providing unnecessary medical services to settle the expenses of basic medical insurance by means of repeated registration for the insured, repeated or unexplained laboratory tests, examination, treatment, decomposition or hospitalization;

(3) in violation of the relevant provisions of the basic medical insurance, the medical expenses generated by the medical insurance fund's payment scope or medical treatment projects and medical service facilities outside the agreed service scope are settled;

(4) In violation of the provisions on the scope or varieties of drugs used in the basic medical insurance, the insured person is filled with drugs by overdose, repeated use of drugs, illegal use of drugs with special restrictions, or the expenses of the basic medical insurance are settled by decomposing or changing prescriptions;

(5) The expenses of basic medical insurance are settled by repeatedly charging, decomposing, exceeding the standard or charging by self-standard;

(6) Failing to settle the expenses of basic medical insurance according to the payment proportion stipulated in the basic medical insurance;

(7) failing to re-apply for the examination and approval procedures for the designated qualification of basic medical insurance in accordance with the provisions of Article 7 of these Measures, and implementing networking for the settlement of basic medical insurance expenses without authorization.

Provisions on Penalties for Serious Violations by Designated Medical Institutions and Designated Retail Drugstores

Anyone who commits one of the following acts will be ordered to make corrections, recover the medical expenses paid by the medical insurance fund, and may be given a warning or a fine ranging from 3, yuan to 1, yuan; If the circumstances are serious, their basic medical insurance settlement relationship will be suspended for one to six months or their designated qualification for basic medical insurance will be cancelled: < P > (1) Networking with non-designated medical institutions or retail pharmacies without authorization to settle the basic medical insurance expenses;

(2) using forged or altered medical records, prescriptions, accounts, medical expense documents, uploaded data, etc. to settle the basic medical insurance expenses;

(3) using non-pharmaceutical articles such as daily necessities and health-care tonics as medicines within the scope of basic medical insurance to settle the expenses of basic medical insurance;

(4) settlement of basic medical insurance expenses by other ways that damage the medical insurance fund.