Study On The Legal Liability Of Fraud In Designated Medical Institution

With the further development of the basic system of medical care insurance,the nonstandard medical events,such as fraud,has occurred frequently and become increasingly acute.Among a variety of subjects involved,the fraud behavior of sentinel medical institutions has become the key concern which should be punished sternly by administrative departments of medical insurance due to its large scale,wide range and great harm.It has been an inevitable trend to standardize medical insurance fraud by using legal means.The legal liability system is an effective mechanism to ensure the realization of rights and the fulfillment of obligations.At present,the law of our country does not clearly define the nature of civil responsibilities for fraud committed by sentinel medical institutions,and the provisions on the administrative and criminal responsibilities that should be undertaken by them have not been fully determined yet,which are not conducive to cracking down the illegal activities,for the civil responsibilities can make up their economic losses completely.Therefore,focusing on the analysis of the civil responsibilities for fraud committed by sentinel medical institutions,this paper makes a brief analysis of the existing problems of the administrative and criminal responsibilities stipulated in the existing law,and put forward some suggestions accordingly,hoping to punish the illegal activities comprehensively and study the problems thoroughly.The main body of this paper consists of four parts.In the first part,the fraudulent conducts and the legal responsibilities of the sentinel medical institutions are defined in detail,based on the guiding ideology of typification,their fraudulent conducts are classified in three aspects,namely,civil,administrative and criminal responsibilities;the second part analyzes the constitution of the legal responsibility of sentinel medical institutions' fraud behaviors,and the constitutive requirements of legal liability are expounded from four aspects,including that the main body is sentinel medical institutions with capacity of bearing legal responsibility,the sentinel medical institutions have conducted fraudulent practices,the institutions concerned have the subjective intention of illegally holding medical insurance funds,and the safety of medical insurance fund is actually damaged;and then,the civilresponsibilities of fraud in sentinel medical institutions has been emphatically analyzed.According to the analysis of the existing legal provisions,it is pointed out that there is a problem in the legislation of civil liability for sentinel medical institutions' fraud in China,which is the ambiguity of the legal nature of medical service agreement and the specific forms of the liabilities for breach of contract.Based on a comparative study of the American civil liability system for medical insurance fraud and the operation mechanism of German social medical insurance,first of all,the legal nature of the sentinel medical service agreements are analyzed and identified as civil contracts;then,when the amounts of fraud have reached or have not reached the sentencing standard of criminal cases,the specific responsibilities for the breach of such contracts are proposed respectively.The fourth part briefly analyzes the administrative and criminal responsibilities of sentinel medical institutions' fraudulent conducts,pointing out that,according to the current legislation,the administrative and criminal responsibilities that should be born in different circumstances vary from each other significantly,which need to be included in the long-term mechanism of joint law enforcement,and the legislative interpretation of social security fraud is not exhaustive enough.Based on the reference of foreign legislation,in order to facilitate the punishment of the circumstances,it is necessary to make detailed rules for fraudulent practices;to crack down on personnel's fraudulent practices in designated medical institutions;to strengthen the construction of joint enforcement mechanism among administrative departments,promoting seamless convergence between administrative enforcement of law and criminal justice;the crime of social insurance fraud should be identified as a separate term and given criminal sanction,that's to say,the penalties for such crime have been enhanced.