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prosecutors from mentougou district procuratorate discuss the case.

leaving beds empty, prescribing false medicines, faking work-related injuries... as the methods of work-related injury insurance fraud become more diverse, the crimes are also characterized by involving a large number of people, lasting for a long time, being process-oriented, and covering a large geographical area. the corresponding illegal and criminal acts are even more difficult to detect.

recently, a report about "hospital beds were left empty and patients visited the hospital 104 times in more than 90 days" became a hot topic, and the issue of insurance fraud for work-related injuries has attracted public attention. recently, the reporter went to the mentougou district procuratorate in beijing to interview a work-related insurance fraud case handled by the procuratorate, which involved profiting from reselling drugs paid for by the work-related injury insurance fund.

from drug dealers to prescribers

in june 2021, police officers from the mentougou branch of the beijing municipal public security bureau seized more than 1,000 boxes of illegally purchased work-related injury medical insurance drugs from the rental residence of drug dealer suo. in july 2022, the case was transferred to the mentougou district procuratorate for review and prosecution.

he xiaoyi, the prosecutor of the criminal prosecution department of mentougou district procuratorate, who is in charge of the case, found anomalies when reviewing the evidence. "we found more than 160 local prescribers in mentougou, as well as four national injection groups and high-quality medicine groups in suo's mobile phone address book," he xiaoyi said. "based on the number of drugs seized from suo's residence and his wechat transaction flow, we believe that drug dealer suo is just a 'middleman' who earns the difference in price, and there may be a larger transaction chain upstream and downstream."

the sisters shi a and shi b were the first prescribers to be caught in the case of suo. in january 2021, shi a saw a small card for collecting medicines on the ground on her way home. after picking it up, she found that it was printed with various medicine names and mobile phone numbers. these small cards were from suo. since january 2021, suo has printed 3,000 small cards for collecting medicines and distributed them in various communities and streets in mentougou district. many residents have picked up such cards.

after seeing the small card, shi a and her sister shi b, who was a nurse in the hospital, hit it off. shi b took advantage of her position and took the medical insurance cards of two relatives to find a familiar doctor to prescribe medicine. she later confessed: "as long as the dosage does not exceed the recommended dosage in the drug instructions, the doctor can prescribe the maximum dosage." shi a was responsible for contacting shi b to get the medicine, and then finding another time to sell the medicine to suo.

strange medical records

after investigation, it was found that from 2020 to 2021, suo illegally purchased drugs paid for by the work-related injury insurance fund and sold them to the public, making a profit of 800,000 yuan. from january to may 2021, shi a and shi b resold more than 800 boxes of work-related injury insurance drugs to suo, making a profit of more than 40,000 yuan. through suo, these drugs were sold to pharmaceutical factories in 13 provinces including heilongjiang, hubei, and chongqing. after purchasing these drugs, the pharmaceutical factories can continue to resell them together with medical representatives and practitioners, earning the difference layer by layer.

after the prosecution was filed by the mentougou district procuratorate, in march this year, the court sentenced the defendant suo to three years in prison and a fine of 30,000 yuan for the crime of concealing and hiding the proceeds of crime; and sentenced the defendants shi a and shi b to one year in prison and suspended for one year for the crime of fraud, and each was fined 10,000 yuan. the remaining persons are still under further investigation.

during the interview, a data sheet of medical treatment visits by criminal suspects compiled by the mentougou district procuratorate caught the reporter's attention: a prescriber went to 32 different hospitals during the nearly one year of illegal drug sales. he visited one of the hospitals more than 900 times, but had only two visits to another hospital, a sharp contrast, and his annual drug prescription costs amounted to 2 million yuan.

liu fanshi, assistant prosecutor of the criminal prosecution department of mentougou district procuratorate, said that many prescribers said that every time they go to the hospital to get a prescription, they ask the doctor to prescribe a dosage that does not exceed the maximum dosage specified in the drug instructions. in order to prescribe more drugs, they even formed a prescription route across different districts, and they could collect hundreds or even thousands of boxes of drugs in one round.

“digital portrait” accurately identifies insurance fraudsters

how can we accurately detect and combat such secretive criminal behavior? on the basis of handling the work-related injury insurance fraud case of suo, the mentougou district procuratorate explored and established a "big data legal supervision model for work-related injury insurance fraud". "we have worked with the district human resources and social security bureau, medical institutions, third-party payment platforms, etc. to retrieve work-related injury insurance data, third-party payment platform data, communication data, etc., and based on the abnormal index of annual average work-related injury fund payments of more than 300,000 yuan, as well as the abnormal increase in drug expenses of workers with work-related injuries, multiple hospitals prescribing drugs on the same day, and repeated prescribing of drugs with the same efficacy, we screened out people with abnormal prescription amounts, and further analyzed whether they had abnormal prescription behavior. finally, we combined transaction records and interrogation situations to identify criminal suspects." li shanshan, director of the criminal prosecution department of the mentougou district procuratorate, said.

this approach has been recognized by yin bo, a professor at the school of criminal justice of china university of political science and law: "in terms of identifying insurance fraud, criminal suspects may use the 'ant moving rice grains' type of insurance fraud or the one-time insurance fraud of large sums of money. for the former, judicial organs have established big data thinking and 'digital portraits' of those who commit work-related insurance fraud, which can accurately identify abnormal behaviors."

up to now, the mentougou district procuratorate has identified more than 500 workers with abnormal amounts of prescription drugs through the "work injury insurance fraud big data legal supervision model", filed cases against more than 30 workers with suspected involvement in defrauding work injury insurance funds, and transferred supervision clues to the public security organs, resulting in criminal cases against 15 people.