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recently, the case of wuxi hongqiao hospital suspected of fraud in obtaining medical insurance has attracted widespread attention from all walks of life.

several lawyers told the paper that, depending on the facts and circumstances of the crime, medical institutions that falsify information to obtain medical insurance may be suspected of fraud, embezzlement, and concealing or hiding the proceeds of crime. if the amount of fraudulent public or private property is particularly huge or there are other particularly serious circumstances, the offender shall be sentenced to more than ten years in prison or life imprisonment, and shall be fined or have his property confiscated.

for the medical institutions involved in the case, the medical insurance administrative department will order them to return the losses caused to the medical insurance funds and impose a fine of not less than twice but not more than five times the amount defrauded; at the same time, they will be ordered to suspend the designated medical institutions from providing medical services involving the use of medical insurance funds for not less than six months but not more than one year until the service agreement is terminated; if they have a practicing license, the relevant competent department will revoke it according to law.

previously, according to a report by dr. zhu chenggang, a considerable number of medical records of patients who had never undergone imaging examinations in their department appeared in the wuxi hongqiao hospital system, which were obviously suspected of fraud. for example, the images of three patients aged 72, 62 and 25 were almost identical. moreover, after dr. zhu's report, their permission to view the images was locked, and they could only use the clumsy method to find the problematic images.

on september 23, the national healthcare security administration sent a special flying inspection team to wuxi hongqiao hospital to carry out flying inspections.

on september 24, the wuxi municipal medical insurance bureau issued a report that the hongqiao hospital's insurance fraud was basically confirmed. on september 22, the hospital was disqualified from being designated as a medical insurance institution, and the public security authorities filed a criminal case. on september 23, the legal representative, the hospital director and 15 other people were taken criminal compulsory measures by the public security authorities. the hospital has now ceased operations.

on september 24, people's daily online learned from the medical insurance bureaus at the suzhou and kunshan levels that an investigation team led by the jiangsu provincial medical insurance bureau has entered kunshan hongqiao hospital, focusing on investigating whether the hospital has problems similar to the wuxi hongqiao hospital in falsifying images to defraud insurance.

what legal sanctions will medical institutions face for fraudulent medical insurance? several lawyers told the paper that, depending on the facts and circumstances of the crime, medical institutions that commit fraudulent medical insurance may be suspected of crimes such as fraud, embezzlement, and concealing and hiding the proceeds of crime.

zhou chuikun, a lawyer at yingke law firm in beijing, introduced that according to the "guiding opinions on several issues concerning the handling of criminal cases of medical insurance fraud" which came into effect on february 28, 2024, medical insurance fraud is not an independent type of crime and does not have a specific criminal law crime. it is a general term for a type of criminal behavior involving multiple crimes.

zhou chuikun said that if medical institutions forge, alter, conceal, tamper with, or destroy medical documents, medical certificates, accounting vouchers, electronic information, test reports, or other related materials for the purpose of illegal possession, or fabricate medical service items, or falsely invoice medical service fees, etc., because medical institutions (units) cannot constitute the crime of fraud, their organizers, planners, and implementers will be convicted and punished for the crime of fraud. "if other crimes are constituted at the same time, they will be convicted and punished in accordance with the provisions with heavier penalties. if state employees of medical institutions commit the above-mentioned acts and defraud medical insurance funds, they will be convicted and punished for the crime of embezzlement."

zhou chuikun also pointed out that "if someone knowingly purchases or sells drugs illegally using medical insurance fraud, he shall be convicted and punished for the crime of concealing or hiding the proceeds of crime. among them, whether the person who uses medical insurance fraud to purchase drugs is held criminally liable does not affect the conviction and punishment of the person who illegally purchases or sells the relevant drugs."

"in addition, the proceeds from medical insurance fraud crimes committed by medical institutions should be recovered according to law," said zhou chuikun.

wang peng, a lawyer at beijing fahuan law firm, also said, "the law has clear punishment measures for the act of defrauding medical insurance. according to the provisions of my country's criminal law and relevant judicial interpretations, if a medical institution uses false means and measures to defraud medical insurance, and the amount is huge, it constitutes the crime of fraud."

according to article 266 of the criminal law of the people's republic of china, defrauding medical insurance funds by fraud, forging certification materials or other means is an act of defrauding public or private property. if the amount of defrauding public or private property is relatively large, the offender shall be sentenced to fixed-term imprisonment of not more than three years, criminal detention or public surveillance, and shall be fined or fined alone; if the amount is huge or there are other serious circumstances, the offender shall be sentenced to fixed-term imprisonment of not less than three years but not more than ten years and shall be fined; if the amount is particularly huge or there are other particularly serious circumstances, the offender shall be sentenced to fixed-term imprisonment of not less than ten years or life imprisonment, and shall be fined or have his property confiscated.

wang peng pointed out that the classic cases released by the supreme people's procuratorate also mentioned that using other people's medical insurance certificates to seek medical treatment or buy medicine under a false name constitutes the crime of fraud.

wang peng also made it clear that "the medical insurance administrative department will order the return of the losses caused to the medical insurance funds and impose a fine of more than 2 times but less than 5 times the amount defrauded; at the same time, it will order the designated medical institutions to suspend medical services involving the use of medical insurance funds for more than 6 months but less than 1 year until the service agreement is terminated; if there is a practicing license, the relevant competent department will revoke it according to law."