New medical insurance fund supervision regulations take effect today: focusing on cracking down on insurance fraud methods such as “car pickup and drop-off,” with a focus on cracking down on the sale and resale of “reimported medicines.”

How can AI · Intelligent Supervision System collaborate through three lines of defense to combat insurance fraud?

According to Xinhua News Agency, on April 1st, the “Implementation Rules for the Supervision and Administration of the Use of Medical Security Funds” (referred to as the “Implementation Rules”) officially came into effect. On March 31st, at a press conference held by the National Healthcare Security Administration, Deputy Director Huang Huabo pointed out that the promulgation and implementation of the “Implementation Rules” will help improve the precision of healthcare fund supervision, better combat illegal and irregular use of healthcare funds and insurance fraud, and enhance the efficiency of healthcare governance. The National Healthcare Security Administration will take this opportunity to develop and improve relevant supporting administrative normative documents, further standardize fund supervision, and improve the quality and efficiency of fund management.

Gurong, Director of the Fund Supervision Department of the National Healthcare Security Administration, stated that the “Implementation Rules” further detail the prominent and typical issues faced in healthcare fund supervision, providing a stronger legal weapon for cracking down on insurance fraud.

It is understood that the “Implementation Rules” consist of 5 chapters and 46 articles, further clarifying the supervisory responsibilities of healthcare administrative departments, the review responsibilities of handling agencies, and the main responsibilities of designated medical institutions, as well as regulations on new areas such as long-term care insurance.

Gurong said that the National Healthcare Security Administration will focus on cracking down on insurance fraud methods such as “car-to-car transfer,” “cost reduction,” “bribery,” and “gifts of rice, flour, and oil.” Participating in illegal activities organized by others with knowledge of their fraudulent behavior, accepting gifts, reducing costs, or providing additional services can be punished as insurance fraud.

Gurong pointed out that efforts will be concentrated on combating issues like the resale of “reflowed drugs.” If designated medical institutions organize others to use healthcare funds to buy drugs or medical consumables fraudulently, and then illegally buy or sell them, it can be identified as insurance fraud; if staff at designated medical institutions knowingly assist others in fake or impersonated medical treatment or drug purchases for the purpose of fraud, it can also be identified as insurance fraud.

He gave an example: during actual supervision, it was found that drug traffickers often carried multiple healthcare vouchers to a hospital to get prescriptions, and medical staff directly cooperated without verifying any identity information or authorization, which constitutes “assisting others in impersonated or false medical treatment or drug purchases.”

Specifically, the “Implementation Rules” detail common personal insurance fraud scenarios, providing a clear “negative list” for law enforcement. First, fraudulently obtaining healthcare benefits by providing false materials or concealing facts, such as medical assistance, outpatient chronic or special disease benefits, long-term residence benefits in other regions, maternity allowances, etc., can be punished as insurance fraud. Second, renting or lending one’s healthcare credentials for illegal profit—long-term handing over of personal healthcare credentials to others, accepting cash, goods, or other illegal benefits in return. Third, impersonating others to enjoy healthcare benefits—using medical service documents or prescriptions issued to other insured persons at designated medical institutions to seek treatment or purchase drugs, thus enjoying benefits fraudulently. Fourth, double benefits—deliberately concealing that medical expenses have been paid by workers’ compensation insurance or a third party, applying for reimbursement from the healthcare agency, and receiving payment, which can be identified as fraud if not returned after reminders.

To prevent designated medical institutions from evading supervision by voluntarily terminating or not renewing agreements, the “Implementation Rules” clearly set up a withdrawal inspection mechanism. When a designated medical institution applies to terminate or not renew a service agreement, the healthcare administrative agency can review past agreement performance, reasons for termination, or conduct a comprehensive check of healthcare fund settlement costs based on the requirements of the healthcare administrative department. If suspected of illegal or contractual violations involving healthcare funds, appropriate handling must be carried out before termination or non-renewal.

Gurong stated that in recent years, while maintaining a high-pressure stance on strict investigation and crackdown, healthcare departments have also attached great importance to combining prevention and control, continuously establishing and improving an intelligent supervision system covering the entire process, all fields, and all chains. This system can be summarized as “three lines of defense” and “two major functions.” The “three lines of defense” include pre-emptive reminders at the medical institution level, real-time review at the handling level, and post-supervision at the administrative level, forming a layered, coordinated effect to intercept illegal activities effectively; the “two major functions” empower healthcare administrative departments, handling agencies, and designated medical institutions. “We have developed dozens of big data supervision models,” Gurong said. To address the practical challenges of extensive, widespread, and long chains of healthcare fund supervision, they utilize big data and artificial intelligence to solve manpower shortages and heavy workloads, building an intelligent supervision rule library and knowledge base to support handling reviews. Simultaneously, they empower designated medical institutions through pre-emptive intelligent reminders to eliminate various illegal issues at the “embryonic” stage, reducing violations.

From the press conference, it was learned that over the past five years, healthcare departments at all levels have recovered approximately 120 billion yuan in healthcare funds, demonstrating significant results in fund supervision. According to the “Statistical Bulletin on the Development of Medical Security in 2025” released by the National Healthcare Security Administration, the national healthcare system recovered 34.2 billion yuan last year, with the intelligent supervision subsystem recovering 3 billion yuan of losses; additionally, through drug traceability codes, targeted crackdowns on the resale of “reflowed drugs” have been carried out across the entire chain, with over 240k suspicious clues checked, 124.7k designated medical institutions inspected, and 39.1k illegal institutions handled. Joint efforts with public security agencies led to 695 cases of “reflowed drug” trafficking cracked, and 2,576 professional fraudsters arrested.

Editor: Wu Qí

Review: Lin Xihe

【Source: Xinhua News Agency】

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