Clearly crack down on behaviors such as inducing hospitalization and reselling medicines for insurance fraud. The new medical insurance regulations will take effect tomorrow.

With the continued improvement of the medical insurance system, some new fraud-and-abuse schemes to骗取 insurance payments have continued to emerge. On March 21, Huang Huabo, deputy director of the National Healthcare Security Administration, revealed that since 2021, medical insurance departments at all levels, through agreement-based handling and administrative penalties, have累计追回 medical insurance funds of more than 120 billion yuan.

Today, new regulatory rules are in place for ordinary people’s “treatment fees” and “life-saving money”—the 《Implementation Rules for the Measures for the Supervision and Administration of the Use of the Medical Security Fund》 (hereinafter referred to as the 《Implementation Rules》) will come into effect on April 1, 2026.

At a press conference held today, the National Healthcare Security Administration stated that the 《Implementation Rules》 provide specific definitions for prominent fraud issues in recent years in medical insurance supervision, such as inducing hospital admissions and trafficking in drugs, thereby offering a clearer legal basis for cracking down on fraud and abuse.

Compared with the 《Measures for the Supervision and Administration of the Use of the Medical Security Fund》 issued in 2021, this 《Implementation Rules》, respectively, set out boundaries for fraudulent conduct for designated medical and pharmaceutical institutions and for individuals.

The 《Implementation Rules》 state that designated medical and pharmaceutical institutions and their staff, by means such as persuading others, making false promotional claims, reducing or waiving fees, or providing additional property or services, and thereby inducing or guiding others to seek treatment or purchase drugs under another person’s name, or through false arrangements, can be deemed to fall within the “inducing others to seek treatment or purchase drugs under another person’s name, or through false arrangements” situation stipulated in the Measures.

Designated medical and pharmaceutical institutions and their staff, knowing that other parties seek to defraud the medical security fund, who still assist them in seeking treatment or purchasing drugs under another person’s name, or through false arrangements, can be deemed to fall within the “assisting others to seek treatment or purchase drugs under another person’s name, or through false arrangements” situation stipulated in the Measures.

In addition, if a designated medical and pharmaceutical institution organizes others to purchase drugs and medical consumables by defrauding medical insurance, and then illegally acquires or sells them; includes non-pharmaceutical expenses in the settlement of medical insurance funds; or carries out settlement again for already settled expenses, among five types of conduct, it will also be punished in accordance with law.

Regarding individuals’ use of medical insurance cards, the 《Implementation Rules》 clarify that six types of conduct can be recognized as being for the purpose of defrauding the medical security fund: using medical service invoices and prescriptions for treatment and drug purchases issued by designated medical and pharmaceutical institutions based on the treatment and purchase by other enrolled persons, and then long-term or repeatedly purchasing or selling basic medical insurance drugs to or from unspecified trading counterparties, among them.

The 《Implementation Rules》 further clarify that if medical security administrative departments discover in their fund supervision work that there are 12 categories of conduct suspected of violating public security administration rules or of constituting a crime—such as organizing fraud, trafficking in medical insurance drugs, or fabricating materials for fraud—they shall promptly transfer the matter to public security authorities.

According to the National Healthcare Security Administration’s 《2025 Statistical Bulletin on the Development of Medical Security Undertakings》, in 2025, across the country the medical insurance system recovered 34.2 billion yuan of medical insurance funds in total; among them, 27.8 billion yuan was recovered through verification and audit review by medical insurance agencies; 1,626 institutions were found to be involved in fraud and abuse; 1,678 cases were handed over to judicial authorities, 19k cases were handed over to disciplinary inspection and supervision authorities, and 59k cases were handed over to administrative departments such as health and healthcare; joint with public security authorities to investigate 3,776 medical insurance cases, arresting 10,357 criminal suspects; and through the intelligent supervision subsystem, recovering 3 billion yuan in losses to medical insurance funds. In 2025, a total of 19k yuan in举报奖励金 was issued nationwide.

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责任编辑：曹睿潼