Identification And Legal Regulation Of Social Medical Insurance Fraud In Medical Institutions

With the expansion of social insurance coverage and the increase of government investment,the fraud in social insurance has become a generalized and normalized trend.In the case of social medical insurance fraud,there are many medical institutions involved,and the fraud is professional,causing serious losses in insurance funds.The fraud in medical institutions has led to the massive loss of the medical insurance pool funds and caused serious adverse social effects and harmful consequences.Therefore,it is an inevitable trend to use effective legal instrument to regulate the fraudulent behaviors of medical institutions.At present,the identification of social medical insurance fraud in medical institutions is limited and lagging-The current Chinese law does not clearly define the connotation and extension of social medical insurance fraud in medical institutions and there are only basic regulations.Local laws and regulations all define social medical insurance fraud in medical institutions in the form of generalization,enumeration,and miscellaneous provisions.The identification and regulation of fraudulent behaviors are relatively simple and crude,and thus various types of fraudulent behaviors have not been deeply analyzed.There are many differences in the nature,harmfulness and legal liability of these frauds,which indirectly leads to the inoperability of the existing legal provisions.Here,this article focused on analyzing the identification and legal regulations of social medical insurance fraud in medical institutions in China.By briefly analyzing the current national and local laws and regulations on the identification of social medical insurance fraud in medical institutions,and drawing on the relevant US laws and regulations and its legislative experience,we put forward relevant suggestions to improve the comprehensiveness and normativeness of identifying and punishing such illegal acts and make the research content more complete and practical.This article used the literature review method to clarify the current research status at home and abroad,and combined the empirical investigation method to investigate the cases of social medical insurance fraud in related medical institutions.The main body of this article is divided into five parts:The first part combined social life practices and mainly explained the purpose and significance of the topic selection research.in this article according to the current Chinese background of social medical insurance fraud.The analysis of the research on social medical insurance fraud in medical institutions in the United States provided the premise and basis for this study.The second part mainly analyzed the nature of social medical insurance fraud in medical institutions by discussing the relevant content and attributes of social medical insurance.And then,based on the analysis of the nature of the social medical insurance pool and the clarification of the attributes of the service agreement of the medical institution,we defined the social medical insurance fraud behaviors of medical institutions from the perspectives of civil,administrative,and criminal.The third part mainly illuminated the existing legislative regulations at the national and local levels.Through collating and summarizing the legal norms for the identification of social medical insurance fraud in medical institutions,we discussed and evaluated the problems existing in the current law.There were five points.First,the national legislation lacks clear provisions for the concept of medical insurance fraud in medical institutions.Second,the social insurance law lacks provisions for medical insurance fraud in medical institutions.Third,he criminal law lacks detailed provisions for the crimes and non-crimes of medical insurance fraud.Fourth,the local legislation for medical institutions Medical insurance fraud is defined as chaotic.Fifth,social medical insurance fraud in medical institutions is not identified based on its social harmfulness.The fourth part mainly listed the US legal system regulations on medical insurance fraud behaviors in medical institutions.By introducing different legal regulations in the United States and analyzing the legal regulations for the identification of medical insurance fraud behaviors in the American medical institutions,we highlighted the meaningful reference from their legal system regulations on medical insurance fraud.The fifth part mainly proposed legal regulations for the identification of social medical insurance fraud in medical institutions and its problems.Based on the existing problems at the national and local levels,combined with the actual situation in China,and drawing on the experience of the United States,we put forward several proposals.First,amend the Social Insurance Law to increase the connotations of social medical insurance.Second,introduce special administrative regulations for social medical insurance fraud in medical institutions.Third,revise the Criminal Law to increase the crimes related to social insurance fraud.Fourth,re-clarify the regulations on social medical insurance fraud in medical institutions in local legislation.Fifth,specify the regulations on social medical insurance fraud in medical institutions based on social hazards.