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Under the guise of welfare activities such as the "Blindness Restoration Project" and "Charity Foundation", they entered villages and towns (communities) in the name of "free clinics", claiming that "cataracts can be treated for free", and lured a large number of elderly people with medical insurance to the hospital's ophthalmology department for "consultation" and receive inpatient surgery "treatment". Afterwards, they defrauded medical insurance funds by tampering with vision data, forging medical records, and issuing false invoices for artificial lenses.

On August 23, the second-instance trial of a case in which a hospital embezzled national medical insurance funds involving a sum of tens of millions of yuan was opened at the Shaoxing Intermediate People's Court. The amount involved in one hospital alone reached more than 20 million yuan. A surgeon, Liu Ming, was involved in the case and was charged with fraud.

The public prosecutor accused the defendant Liu of assisting in defrauding medical insurance funds of more than 10 million yuan during his tenure. Liu was convicted of fraud at first instance and sentenced to three years and six months in prison. Liu insisted that he was not guilty because, as a surgeon, he did not participate in the decision-making and management of ophthalmology. Whether the attending physician was aware of the situation became one of the focuses of the trial.

On August 24, a reporter from Xiaoxiang Morning News learned from Liu Mouming's family that in the second trial, Liu Mouming still insisted that he was not guilty. The case will be sentenced at a later date.

Three hospitals accused of embezzling tens of millions of yuan from medical insurance funds by offering "free clinics" to elderly people with medical insurance to treat cataracts

There are three defendants in this case.

The verdict obtained by the reporter of Xiaoxiang Morning News shows that one of the defendants, Liu Mingming, 55 years old, was formerly an ophthalmologist at Shaoxing Paojiang Hospital and Chouzhou Hospital. Zhu was formerly an ophthalmologist at Yiwu Chouzhou Hospital and Mingsheng Ophthalmology Hospital. Zhao was formerly a staff member of the marketing department of Chouzhou Hospital.

The first instance prosecution agency alleged that from January 2017 to April 2020, Lin Mouyang, You Moumin (both prosecuted in separate cases) and Lin Mouhua (handled in separate cases) and others conspired and agreed to jointly invest in the contracting of the ophthalmology department of Shaoxing Paojiang Hospital Co., Ltd. in the name of "Shanghai Huagang Hospital Investment Management Co., Ltd." to embezzle the national medical insurance fund. They recruited the defendants Liu Mouming and Li Mou (prosecuted in separate cases) as medical staff, recruited many members of the market diversion team, and entered villages and towns (communities) under the guise of welfare activities such as "Restoring Blindness Project" and "Charity Foundation", claiming that "cataract disease can be treated at only part of the self-funded or free of charge", and lured a large number of elderly people with medical insurance to the hospital's ophthalmology department for "consultation" and receive inpatient surgery for "treatment".

The above-mentioned personnel customized diagnosis and treatment templates based on the medical insurance reimbursement items and rules, and defrauded medical insurance funds by reversing the reimbursement approval process, tampering with vision data, forging medical records, and falsely issuing artificial lens invoices. By the time the case was discovered, a total of more than RMB 21 million in medical insurance funds had been defrauded. The defendant Liu Mouming participated in assisting in defrauding medical insurance funds of RMB 8.0103 million during his tenure.

From August 2017 to 2019, Lin Mouhua contracted the ophthalmology department of Yiwu Chouzhou Hospital in the name of "Shanghai Huagang Hospital Investment Management Co., Ltd." to embezzle medical insurance funds. He recruited defendants Liu Mouming and others as medical staff, and recruited defendants Zhu Moumou, Zhao Moumou and others as marketing staff, and embezzled medical insurance funds in the same way. By the time the case was discovered, a total of more than RMB 4.7 million in medical insurance funds had been embezzled. During his tenure, defendant Liu Mouming participated in assisting in embezzling RMB 2.4913 million in medical insurance funds, and defendants Zhu Moumou and Zhao Moumou participated in assisting in embezzling RMB 4.577 million in medical insurance funds during their tenure.

Another criminal fact accused by the public prosecution agency involved Yiwu Mingsheng Eye Hospital, and the defendant Zhu was involved in the case. Before the case was discovered, people including Zhu had jointly defrauded medical insurance funds totaling RMB 9.1941 million.

The documents show that other investors, department heads and hospital staff were also involved in this case and were all dealt with separately.

Shareholders of the ophthalmology department of the hospital involved in the case: They assumed the self-paid portion of the patients in the name of a charitable foundation, but in reality they were transferring the money from one hand to the other.

According to the verdict, You Moumou, a shareholder of the hospital involved in the case, confessed that the way the Ophthalmology Department of Paojiang Hospital obtained medical insurance was to advance the self-paid portion of the patients through a charitable foundation that cooperated with the Ophthalmology Department. The patients were packaged as people who met the conditions of the foundation, and then the foundation was asked to waive the self-paid portion of the patients, but the money actually paid by the foundation was from the Ophthalmology Department. In fact, the money earned by the Ophthalmology Department would be donated to the foundation again.

Another non-accomplice in the same case, Feng Moulong, confessed that he was specifically responsible for publicity and diversion work, and simple free clinics. Specifically, he wore a white coat and used a slit lamp to check the eyes of the elderly, but he did not know how to check. He just lied to the elderly that they had cataracts, which would become more serious if they did not have surgery. He advertised that they could be taken to the eye department of Chouzhou Hospital for surgery for free, and the elderly could be exempted from the self-paid part.

Feng Moulong confessed that these were all taught by the ophthalmology shareholders, who also taught him various rhetoric. He cheated the country's money by performing cataract surgeries on the elderly in batches, because this was a common practice in the industry and many hospitals did so, and he did not realize the seriousness of the situation.

"Chouzhou Hospital is sometimes particularly extreme. Patients with vision of around 0.5 or even above 0.5 are taken to the hospital for surgery."

Feng Moulong confessed that the policy stipulates that naked eye vision below 0.3 can be reimbursed, but in order to obtain more commissions, the diversion staff brought many patients with vision above 0.3 to the hospital. These people eventually used medical insurance, which means that the patients' vision must have been tampered with after they were taken to the hospital. Many patients have good vision and do not need surgery, but the doctors are also performing surgery on them. The hospital's shareholder managers know that the ophthalmology department is operating in this way to defraud the national medical insurance fund, and it is a routine they came up with.

A staff member who was responsible for bringing patients to the hospital confessed that after the elderly arrived at the hospital, the ophthalmology department would arrange for doctors to examine them, and the results of the examinations mostly showed that they had cataracts. "Anyway, they would rely on cataracts and try their best to get them to undergo surgery."

Whether the surgeon was aware of the situation became the focus of the case

The verdict document shows that in the first instance, Zhu and Zhao, who were both marketing staff, pleaded guilty and accepted punishment, but Liu, the surgeon, insisted that he was not guilty.

The public prosecutor accused the hospital of treating some patients with vision higher than 0.3, and then tampering with the medical records so that the patients could meet the medical insurance reimbursement conditions. In addition, the hospital also replaced the so-called imported artificial lenses with domestic artificial lenses, reimbursed them in the name of imported artificial lenses, and reimbursed ordinary incisions as micro-incisions. At the same time, some files were produced to prove that some patients said their conditions worsened after the operation. The public prosecutor accused Liu Mouming of participating in this.

During the trial, the defendant Liu Mouming argued that he did not participate in defrauding medical insurance funds, and he even refused the hospital's request to modify the patient's actual vision for the purpose of defrauding insurance.

The defense lawyer of the defendant Liu Mouming stated that the defendant Liu Mouming was only a surgeon and did not participate in the decision-making and management of the ophthalmology department. Liu Mouming had no shares in the ophthalmology departments of Paojiang Hospital and Chouzhou Hospital. He was a surgeon and not a member of the management team. He had no right to participate in decision-making and management, and had no way of knowing core matters such as finance.

In addition, the defendant Liu Mouming did not participate in the purchase of artificial lenses, nor did he know the purchase price. This is the core secret of the hospital, and the use of artificial lenses is not linked to Liu Mouming's income, so he has no motivation to change the type of artificial lenses during surgery.

The defense attorney also stated that there is no mandatory requirement for cataract surgery to require vision below 0.3, and there is also evidence that the medical insurance department does not refuse to reimburse patients with vision greater than 0.3. The evidence in the case also cannot prove that the defendant Liu Mouming performed cataract surgery on patients who did not meet the conditions for cataract surgery.

Regarding whether Liu Mingming was aware of the incident, the public prosecution agency presented multiple witness testimonies.

According to the confession of another surgeon, Dr. Li, the doctor knew that the medical records and vision data had been modified during the operation. The defendant Liu Ming should also have known this fact, but he performed the cataract surgery without verifying most of the vision test results.

Huang, another non-co-defendant who worked in the marketing department of Chouzhou Hospital, said that hospital management would ask doctors to deliberately write down the patient's vision to meet the indications for cataract surgery, and then arrange the surgery. They asked Liu to change it, but Liu disagreed and asked them to find the resident doctor to change it, because the medical records were handled by the resident doctor, so they later went to find the resident doctor.

The defense believes that these testimonies are all inferential statements.

Regarding the question of whether Liu Mouming was aware of the situation, the first instance court held that the cataract surgery performed by the defendant Liu Mouming was an important part of the medical insurance fraud and illegal gains by the ophthalmology departments of Paojiang Hospital and Chouzhou Hospital. When other people in the department were well aware of the insurance fraud model involved in the case, the defendant Liu Mouming, as the chief surgeon who managed the hospital doctors, expressed his defense that he did not understand the department's insurance fraud operation process, which was obviously unreasonable. He was still responsible for performing cataract surgery and obtaining high commissions when he knew that the department had insurance fraud, and he also had the subjective intention of fraud. After evaluating the risks and effects of the surgery, he did not perform cataract surgery on individual patients. This was a choice he made to reduce the risk of exposure to his criminal behavior, and the nature of his criminal behavior cannot be denied.

In the first instance judgment, Liu Mouming, Zhu Moumou and Zhao Moumou were convicted of fraud. Liu Mouming was sentenced to three years and six months in prison, Zhu Moumou was sentenced to three years in prison, suspended for four years, and Zhao Moumou was sentenced to two years in prison, suspended for three years.

The second trial has begun and the case will be pronounced on a later date

On August 24, Xiaoxiang Morning News reporter learned from Liu Mouming's family that Liu Mouming appealed after the first trial. On August 23, the second trial of the case was held in the Shaoxing People's Court.

According to family members, during the second trial, Liu Mouming still insisted that he was innocent, and his defense lawyer also defended him.

The case file shows that Liu Mouming confessed that his friend knew Lin Mouhua, the boss of Paojiang Hospital's ophthalmology department, so he introduced him to the ophthalmology department of Paojiang Hospital. The salary was guaranteed to be 50,000 yuan, and a certain number of surgeries had to be performed, but he did not remember how many. If the number of surgeries exceeded the specified number, an additional bonus of about 200 yuan per operation would be given. The minimum salary of Chouzhou Hospital was 40,000 yuan, and the rest was similar to that of Paojiang Hospital.

According to family members, Liu Mouming studied at Hunan Medical University (the predecessor of Xiangya Medical College) for undergraduate studies, and was later assigned to a public hospital in Liaoning. He resigned more than 10 years ago and joined a private hospital. He is a doctor who can perform phacoemulsification of cataracts, all-femtosecond, half-femtosecond, excimer laser, and ICL lens implantation. After resigning from the hospital involved in the case, he went to a hospital in Guangzhou to continue working as an ophthalmologist, with an annual income of more than 1.5 million yuan.

"Around 2017, there were only about a thousand or so phacoemulsification cataract surgeons in the country, and cataract surgery was in full swing across the country. Surgeons were in short supply, and an annual income of 600,000 to 1 million was the basic market price. If he didn't work in the ophthalmology departments of Shaoxing Paojiang Hospital and Yiwu Chouzhou Hospital, his income working in other hospitals would not be bad. I can't understand why he would commit a crime just to earn a high income," said the family member.

Fu Jian, a well-known criminal defense lawyer and director of Henan Zejin Law Firm, believes that in this case, the attending doctor Liu insisted that he was not guilty, claiming that he did not participate in the decision-making and management of the ophthalmology department and was not aware of the insurance fraud. Looking at this case, if Liu knew about the hospital's insurance fraud and participated in it, then they may be considered accomplices and need to bear corresponding legal responsibilities. However, if Liu was not aware of the hospital's insurance fraud and his actions were limited to performing normal medical duties, then he may not be convicted.

In this case, if there is evidence that Liu knew that the hospital was engaged in insurance fraud and still participated in the operation and profited from it, then this would be unfavorable to him. On the contrary, if there is no such evidence, or the evidence is insufficient to prove that he was aware of it, then he may not be convicted. Objectively, whether Liu had any improper behavior during the operation is also an important basis for determining whether he was aware of it.

Xiaoxiang Morning News reporter Cao Wei