【中英文对照版】关于办理医保骗保刑事案件若干问题的指导意见.docx

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1、最高人民法院、最高人民检 察院、公安部印发关于办 理医保骗保刑事案件若干问 题的指导意见的通知各省、自治区、直辖市高级 人民法院、人民检察院、公 安厅（局），解放军军事法 院、军事检察院，新疆维吾 尔自治区高级人民法院生产 建设兵团分院，新疆生产建 设兵团人民检察院、公安 局：最高人民法院、最高人民检察院、公安部关于办理医保骗保刑事案件若干问题的指导意见GuidingOpinionsoftheSupremePeople,sCourt,theSupremePeople,sProcuratorate,andtheMinistryofPublicSecurityonSeveralIssuesConc

2、erningtheHandlingofCriminalCasesofMedicalInsuranceFrauds制定机关：国务院办公厅发文字号：国办发20247号公布日期：2024.02.06施行日期：2024.02.06效力位阶：国务院规范性文件法规类别：资源综合利用IssuingAuthority：SupremePeoplesCourtSupremePeoplesProcuratorateMinistryofPublicSecurityAreaofLaw：CrimesandCriminalResponsibilityGeneralProvisionsonInsurance1.evelofA

3、uthority：DocumentsofJudicialInterpretationNatureDateIssued：02-28-2024EffectiveDate：02-28-2024NoticebytheSupremePeoplesCourt,theSupremePeoplesProcuratorate,andtheMinistryofPublicSecurityofIssuingtheGuidingOpinionsonSeveralIssuesConcerningtheHandlingofCriminalCasesofMedicalInsuranceFraudsThehigherpeop

4、le,scourts,people,sprocuratorates,andpublicsecuritydepartments(bureaus)ofallprovinces,autonomousregions,andmunicipalitiesdirectlyundertheCentralGovernment;theMilitaryCourtandtheMilitaryProcuratorateofthePeoplesLiberationArmy;andtheProductionandConstructionCorpsBranchoftheHigherPeoplesCourtofXinjiang

5、UygurAutonomousRegion,andthePeoplesProcuratorateandthePublicSecurityBureauofXinjiangProductionandConstructionCorps:security funds, and rights and interests security, in light of Peoples Court,Forthepurposesofcrackingdownonthecrimesofmedicalinsurancefraudsaccordingtothelaw,effectivelysafeguardingthes

6、ecurityofthemedicalsafeguardingthelegitimateofthepeopleinmedicalworkreality,theSupremetheSupremePeople,sProcuratorateandtheMinistryofPublicSecurityherebyjointlyissuetheGuidingOpinionsonSeveralIssuesConcerningtheHandlingofCriminalCasesofMedicalInsuranceFraudsforyourdiligentimplementationandcompliance

7、.ProblemsencounteredintheimplementationshallberespectivelyreportedtotheSupremePeople,sCourt,theSupremePeoplesProcuratorate,andtheMinistryofPublicSecurityinatimelymanner.SupremePeoplesCourtSupremePeoplesProcuratorateMinistryofPublicSecurityFebruary28j2024GuidingOpinionsoftheSupremePeople,sCourt,theSu

8、premePeoplesProcuratoratejandtheMinistryofPublicSecurityonSeveralIssuesConcerningtheHandlingofCriminalCasesofMedicalInsuranceFrauds为依法惩治医保骗保犯罪， 切实维护医疗保障基金安 全，维护人民群众医疗保障 合法权益，结合工作实际， 最高人民法院、最高人民检 察院、公安部现联合印发 关于办理医保骗保刑事案 件若干问题的指导意见， 请认真贯彻执行。执行中遇 到的重大问题，请分别报告 最高人民法院、最高人民检 察院、公安部。最高人民法院最高人民检察院公安部2024年2月

9、28日最高人民法院、最高人民检 察院、公安部关于办理医保 骗保刑事案件若干问题的指 导意见为依法惩治医保骗保犯罪，维护医疗保障基金安全，维护人民群众合法权益，根据中华人民共和国刑法、中华人民共和国刑事诉讼法等有关规定，现就办理Forthepurposesofcrackingdownoncrimesofmedicalinsurancefrauds,safeguardingthesecurityofthemedicalsecurityfunds,andsafeguardingthelegitimaterightsandinterestsofthepeople,inaccordancewiththe

10、relevantprovisionsoftheCriminalLawofthePeoplesRepublicofChinaandtheCriminalProcedureLawofthePeoplesRepublicofChina,thefollowingopinionsonseveralissuesconcerningthehandlingofcriminalcasesofmedicalinsurancefraudsareherebyputforward.I.Comprehensivelyunderstandingthegeneralrequirements1. Deeplyunderstan

11、dingthesignificanceofcrackingdownonthecrimeofmedicalinsurancefraudsaccordingtothelaw.Themedicalsecurityfundisthepeoples,tmoneyforseeingdoctorsandlifesavingmoney,whichisrelatedtothevitalinterestsofthepeople,thesoundandsustainabledevelopmentofthemedicalsecuritysystem,andthelong-termstabilityofthestate

12、.Thepoliticalpositionshallbeeffectivelyimproved,thesignificanceofcrackingdownonthecrimeofmedicalinsurancefraudsaccordingtothelawshallbedeeplyunderstood,therenovationofproblemsofmedicalinsurancefraudsshallbecontinuouslydeepened,thecrimeofmedicalinsurancefraudsshallbeseverelycrackeddownonaccordingtoth

13、elaw,thesecurityofthemedicalsecurityfundsshallbeeffectivelysafeguarded,thelegitimaterightsandinterestsofthepeoplesmedicalsecurityshallbesafeguarded,thesoundandsustainabledevelopmentofthemedicalsecuritysystemshallbepromoted,andthepeoplessenseofgain,happiness,andsecurityshallbeconstantlyimproved.医保骗保刑

14、事案件若干问题 提出如下意见。一、全面把握总体要求1 .深刻认识依法惩治医保骗 保犯罪的重大意义。医疗保 障基金是人民群众的“看病 钱”、“救命钱”，事关人 民群众切身利益，事关医疗 保障制度健康持续发展，事 关国家长治久安。要切实提 高政治站位，深刻认识依法 惩治医保骗保犯罪的重大意 义，持续深化医保骗保问题 整治，依法严惩医保骗保犯 罪，切实维护医疗保障基金 安全，维护人民群众医疗保 障合法权益，促进医疗保障 制度健康持续发展，不断提 升人民群众获得感、幸福 感、安全感。2 .坚持严格依法办案。坚持 以事实为根据、以法律为准 绳，坚持罪刑法定、证据裁 判、疑罪从无等法律原则， 严格按照证据

15、证明标准和要 求，全面收集、固定、审查 和认定证据，确保每一起医 保骗保刑事案件事实清楚，2. Insistingonhandlingcasesinstrictaccordancewiththelaw.Basingonfactsandtakinglawasthecriterionshallbeinsistedon,thelegalprinciplessuchasprincipleofnullapoenasineIege(nocrimewithoutlaw),evidentiaryadjudication,andnopunishmentindoubtfulcasesshallbeinsisted

16、on,instrictaccordancewiththestandardsandrequirementsforevidenceproof,evidenceshallbecomprehensivelycollected,fixed,reviewedandidentified,toensurethatthefactsineverycriminalcaseofmedicalinsurancefraudareclear,theevidencewasreliableandsufficient,theconvictionisaccurate,thesentencingisappropriate,andth

17、eprocedureislegal.Thecriminalpolicyofcombiningleniencywithseverityandthesystemofleniencyforpleadingguiltyandacceptingpunishmentshallbeeffectivelyimplemented,strictnessandleniencyshallbeachieved,ifnecessary,leniencyshallbecombinedwithseverity,andduepunishmentforcrimesshallbeachieved,toensureproportio

18、nalitybetweencrimeandpunishmentandunityofpolitical,legalandsocialeffects.3. Insistingondivisionoflabor,mutualcooperationandmutualrestriction.Publicsecurityorgans,peoplesprocuratoratesandpeople,scourtsshallfullymaximizethefunctionsofinvestigation,prosecutionandtrial,strengthencooperation,establishalo

19、ng-termworkingmechanism,formjointworkingforce,andcrackdownonthecrimeofmedicalinsurancefraudsinatimelyandeffectivemanneraccordingtothelaw.Thetrial-centeredprincipleshallbeinsistedon,theawarenessofevidence,procedureandjudgmentshallbestrengthened,thedecisiveroleofcourthearingsinascertainingfacts,identi

20、fyingevidence,protectinglitigationrightsandmakingfairjudgmentsshallbefullymaximized,andlegalsupervisionshallbeeffectivelystrengthened,toensurestrictlawenforcementandfairjustice,andenhancejudicialcredibility.II.Accuratelyidentifyingthecrimeofmedicalinsurancefrauds证据确实、充分，定罪准 确，量刑适当，程序合法。 切实贯彻宽严相济刑事政策

21、 和认罪认罚从宽制度，该宽 则宽，当严则严，宽严相 济，罚当其罪，确保罪责刑 相适应，实现政治效果、法 律效果和社会效果的统一。3,坚持分工负责、互相配 合、互相制约。公安机关、 人民检察院、人民法院要充 分发挥侦查、起诉、审判职 能作用，加强协作配合，建 立长效工作机制，形成工作 合力，依法、及时、有效惩 治医保骗保犯罪。坚持以审 判为中心，强化证据意识、 程序意识、裁判意识，充分 发挥庭审在查明事实、认定 证据、保护诉权、公正裁判 中的决定性作用，有效加强 法律监督，确保严格执法、 公正司法，提高司法公信 力。二、准确认定医保骗保 犯罪4.本意见所指医保骗保刑事 案件，是指采取欺骗手段，

22、骗取医疗保障基金的犯罪案 件。4. CriminalcasesofmedicalinsurancefraudasmentionedintheseOpinionsrefertocriminalcasesofdefraudingofmedicalsecurityfundsbyfraudulentmeans.Medicalsecurityfundsshallincludebasicmedicalinsurance(includingmaternityinsurance)funds,medicalassistancefunds,large-amountmedicalexpensessubsidiesf

23、oremployees,medicalsubsidiesforcivilservants,andseriousillnessinsurancefundsforresidents,amongothers.5. Whereadesignatedmedicalinstitution(medicalinstitutionormedicinalproductdistributor)defraudsofthemedicalsecurityfundsbycommittingoneofthefollowingactsforthepurposeofillegalpossession,thepersonwhoha

24、sorganized,plannedorconductedtheactshallbeconvictedandpunishedforthecrimeoffraudinaccordancewiththeprovisionsofArticle266oftheCriminalLaw;andwhereothercrimeshavebeenconcurrentlyconstituted,theviolatorshallbeconvictedandpunishedinaccordancewiththeprovisionsonheavierpunishment:(1) Itinducesorassistsot

25、hersinseekingmedicaltreatmentorpurchasingdrugsunderothers*names,providesfalsecertificationmaterials,orcolludeswithothersinissuingfalsepaymentdocuments.(2) Itforges,alters,conceals,correctsordestroysmedicaldocuments,medicalcertificates,accountingvouchers,electronicinformation,testreportsandotherrelev

26、antmaterials.(3) Itfabricatesmedicalserviceitemsandfalselycollectsmedicalservicefees.医疗保障基金包括基本医疗 保险(含生育保险)基金、 医疗救助基金、职工大额医 疗费用补助、公务员医疗补 助、居民大病保险资金等。5.定点医药机构(医疗机 构、药品经营单位)以非法 占有为目的，实施下列行为 之一，骗取医疗保障基金支 出的，对组织、策划、实施 人员，依照刑法第二百六十 六条的规定，以诈骗罪定罪 处罚；同时构成其他犯罪 的，依照处罚较重的规定定 罪处罚：(1)诱导、协助他人冒名或 者虚假就医、购药，提供虚 假证明材

27、料，或者串通他人 虚开费用单据；(2)伪造、变造、隐匿、涂 改、销毁医学文书、医学证 明、会计凭证、电子信息、 检测报告等有关资料；(3)虚构医药服务项目、虚 开医疗服务费用；(4)分解住院、挂床住院;(4) Itconductsdecompositionofhospitalizationorcounterfeithospitalization.(5) Itcollectsfeesrepeatedlyandbeyondtheprescribedrates,orconductsdecompositionoffees.(6) Itexchangesdrugs,medicalsupplies,dia

28、gnosisandtreatmentitemsandservicefacilities.(7) Itincludesthemedicalexpensesbeyondthescopeofpaymentofhealthcaresecurityfundsinhealthcaresecurityfundsforsettlement.(8) Itconductsotheractsofdefraudingexpenditureofthemedicalsecurityfunds.of (8)其他骗取医疗保障基金Themedicalsecurityfundsfraudulentlyobtainedbyades

29、ignatedmedicalinstitutionthroughtheactsprescribedintheprecedingparagraphshallberecovered.Statefunctionariesofadesignatedmedicalinstitutionwho,bytakingadvantageoftheirpositions,committheactsprescribedinparagraph1todefraudofmedicalsecurityfundsshallbeconvictedandpunishedforthecrimeofembezzlementinacco

30、rdancewiththeprovisionsofArticles382and383oftheCriminalLaw.(5)重复收费、超标准收 费、分解项目收费；(6)串换药品、医用耗材、 诊疗项目和服务设施；(7)将不属于医疗保障基金 支付范围的医药费用纳入医 疗保障基金结算；支出的行为。定点医药机构通过实施前款 规定行为骗取的医疗保障基 金应当予以追缴。定点医药机构的国家工作人 员，利用职务便利，实施第 一款规定的行为，骗取医疗 保障基金，依照刑法第三百 八十二条、第三百八十三条 的规定，以贪污罪定罪处 罚。6.行为人以非法占有为目 的，实施下列行为之一，骗 取医疗保障基金支出的，依 照刑

31、法第二百六十六条的规 定，以诈骗罪定罪处罚；同 时构成其他犯罪的，依照处 罚较重的规定定罪处罚：6.AperpetratorwhodefraudsofthemedicalsecurityfundsbycommittingoneofthefollowingactsforthepurposeofillegalpossessionshallbeconvictedandpunishedforthecrimeoffraudinaccordancewiththeprovisionsofArticle266oftheCriminalLaw;andwhereothercrimeshavebeenconcurr

32、entlyconstituted,theviolatorshallbeconvictedandpunishedinaccordancewiththeprovisionsonheavierpunishment:(1) Itforges,alters,conceals,correctsordestroysmedicaldocuments,medicalcertificates,accountingvouchers,electronicinformation,testreportsandotherrelevantmaterials.(2) Itusesanotherpersonshealthcare

33、securitycertificatetoseekmedicaltreatmentorpurchasedrugs.(1)伪造、变造、隐匿、涂 改、销毁医学文书、医学证 明、会计凭证、电子信息、 检测报告等有关资料；(2)使用他人医疗保障凭证 冒名就医、购药；(3)虚构医药服务项目、虚 开医疗服务费用；(3) Itfabricatesmedicalserviceitemsandfalselycollectsmedicalservicefees.(4) It obtains repeatedly.healthcaresecuritybenefits(4)重复享受医疗保障待遇；(5)利用享受医疗保障

34、待遇 的机会转卖药品、医用耗材 等，接受返还现金、实物或 者获得其他非法利益；(6)其他骗取医疗保障基金 支出的行为。参保人员个人账户按照有关 规定为他人支付在定点医疗 机构就医发生的由个人负担 的医疗费用，以及在定点零 售药店购买药品、医疗器 械、医用耗材发生的由个人 负担的费用，不属于前款第 (2)项规定的冒名就医、购 药。(5) Ittakesadvantageofhisorheraccesstohealthcaresecuritybenefitstoreselldrugs,acceptreturnincashorinkind,orobtainotherillegalbenefits.(

35、6) Itconductsotheractsofdefraudingofexpenditureofthemedicalsecurityfunds.Thepaymentofmedicalexpensestobeassumedbyanindividualandincurredatadesignatedmedicalinstitutionandpaymentofexpensestobeassumedbyanindividualforthepurchaseofmedicinalproducts,medicalequipmentandmedicalconsumablesatadesignatedreta

36、ilpharmacybythepersonalaccountofaninsuredpersonaccordingtotherelevantprovisionsshallnotfallunderthecircumstanceofseekingmedicaltreatmentandpurchasingmedicinalproductsunderanother,snameasprescribedinitem(2)oftheprecedingparagraph.7.医疗保障行政部门及经办 机构工作人员利用职务便 利，骗取医疗保障基金支出 的，依照刑法第三百八十二 条、第三百八十三条的规 定，以贪污罪定

37、罪处罚。8.以骗取医疗保障基金为目 的，购买他人医疗保障凭证 （社会保障卡等）并使用， 同时构成买卖身份证件罪、 使用虚假身份证件罪、诈骗 罪的，以处罚较重的规定定 罪处罚。(7) Anemployeeofamedicalsecurityadministrativedepartmentoragencywho,bytakingadvantageofhisposition,defraudsoftheexpenditureofthemedicalsecurityfundsshallbeconvictedandpunishedforthecrimeofembezzlementinaccordancew

38、iththeprovisionsofArticles382and383oftheCriminalLaw.(8) Forthepurposeofdefraudingofthemedicalsecurityfunds,anypersonwhopurchasesandusesanotherpeoplesmedicalsecuritycertificate(socialsecuritycard,etc.),andconcurrentlyconstitutesthecrimeoftradingidentitycards,thecrimeofusingfalseidentitycards,andthecr

39、imeoffraudshallbeconvictedandpunishedinaccordancewiththeprovisionsonheavierpunishment.盗窃他人医疗保障凭证（社 会保障卡等），并盗刷个人 医保账户资金，依照刑法第 二百六十四条的规定，以盗 窃罪定罪处罚。Anyonewhostealsanotherpersonsmedicalsecuritycertificate(socialsecuritycard,etc.)andstealsfundsinapersonalmedicalinsuranceaccountshallbeconvictedandpunished

40、forthecrimeoftheftinaccordancewiththeprovisionsofArticle264oftheCriminalLaw.9.明知系利用医保骗保购买 的药品而非法收购、销售 的，依照刑法第三百一十二 条和相关司法解释的规定， 以掩饰、隐瞒犯罪所得罪定 罪处罚；指使、教唆、授意 他人利用医保骗保购买药 品，进而非法收购、销售， 依照刑法第二百六十六条的 规定，以诈骗罪定罪处置。(9) Anyonewhoillegallypurchasesorsellsmedicinalproductsthoughheorsheknowsperfectlywellthatthemed

41、icinalproductshavebeenpurchasedbyhealthinsurancefraudshallbeconvictedofandpunishedforthecrimeofdisguisingorconcealingcriminalproceedsinaccordancewiththeprovisionsofArticle312oftheCriminalLawandrelevantjudicialinterpretations;andanyonewhoincites,instigates,orinspiresotherstopurchasemedicinalproductsb

42、yhealthinsurancefraud,andthenillegallypurchasesandsellssuchmedicinalproductsshallbeconvictedofandpunishedforthecrimeoffraudaccordingtotheprovisionsofArticle266oftheCriminalLaw.利用医保骗保购买药品的行Whetheraperpetratorwhopurchasesmedicinal为人是否被追究刑事责任， 不影响对非法收购、销售有 关药品的行为人定罪处罚。productsbyhealthinsurancefraudishe

43、ldcriminallyliableshallnotaffecttheconvictionandpunishmentoftheperpetratorillegallypurchasingandsellingrelevantmedicinalproducts.对第一款规定的主观明知， 应当根据药品标志、收购渠 道、价格、规模及药品追溯 信息等综合认定。具有下列 情形之一的，可以认定行为 人具有主观明知，但行为人 能够说明药品合法来源或作 出合理解释的除外：Subjectiveknowledgeasprescribedinparagraph1shallbecomprehensivelydeterm

44、inedbasedonmedicinalproductlabels,purchasechannels,price,scale,andmedicinalproducttraceabilityinformation,amongothers.Underanyofthefollowingcircumstances,itmaybedeterminedthattheperpetratorhassubjectiveknowledge,exceptwhenthelegitimatesourcesofmedicinalproductsmaybeexplainedorareasonableexplanationm

45、aybegiven:(1)药品价格明显异于市场 价格的；(1) Thepriceofthemedicinalproductissignificantlydifferentfromthemarketprice.(2)曾因实施非法收购、销 售利用医保骗保购买的药 品，受过刑事或行政处罚 的；(2) Hehasbeensubjectedtocriminaloradministrativepunishmentforillegallypurchasingorsellingmedicinalpurchasedbytakingadvantageofmedicalinsurancefraud.(3)以非法收购

46、、销售基本 医疗保险药品为业的；(3) Heillegallypurchasesandsellsmedicinalproductsunderbasicmedicalinsuranceforbusiness.(4)长期或多次向不特定交 易对象收购、销售基本医疗 保险药品的；(4) Hepurchasesandsellsmedicinalproductsunderbasicmedicalinsurancefromandtononspecifictransactionobjectsforalongtermormultipletimes.(5)利用互联网、邮寄等非 接触式渠道多次收购、销售 基本医疗保

47、险药品的；(5) HeusestheInternet,mailandothernon-contactchannelstopurchaseandsellmedicinalproductsunderbasicmedicalinsuranceformultipletimes.(6)Othercircumstancesunderwhichitissufficienttodeterminethesubjectiveknowledgeoftheperpetrator.(6)其他足以认定行为人主观明知的。III.Crackingdownonthecrimeofmedicalinsurancefraudacc

48、ordingtothelaw三、依法惩处医保骗保犯罪10.Criminalscommittingmedicalinsurancefraudsshallbestrictlypunished,backroomorganizersandprofessionalmedicalinsurancefraudsters,amongothers,shallbemainlycrackeddownon,andtheextentofleniencyshallbestrictlygraspedforthosewhoreturnthestolengoodsandmakecompensation,pleadguiltyandacceptpunishment,andfallundercircumstancesofleniency.10.依法从严惩处医保骗保犯罪，重点打击幕后组织者、职业骗保人等，对其中具有退赃退赔、认罪认罚等从宽情节的，也要从严把握从宽幅度。Underanyofthefollowingcircumstances,theviolatormaybesubjecttoheavierpunishment:具有下列情形之一的，可以从重处罚：(1)Heorganizesordirectscriminalgangstodefraudofmedicalsecurityfunds.(1)组