Based on the "Typical Cases of Individuals Defrauding Medical Insurance Funds (Second Issue)" released by the National Healthcare Security Administration, this paper conducts an in-depth analysis of the phenomenon of seeking medical treatment and purchasing medications under false identities, which poses a serious threat to the security of medical insurance funds. The study finds that among the disclosed typical cases, instances of seeking medical treatment and purchasing medications under false identities account for a relatively high proportion of individual fraud cases, exhibiting trends of diversified methods, industrialized chains, and targeted objectives. The paper thoroughly examines the primary causes of such fraudulent behaviors, further revealing that the real-name policy for medical treatment and medication purchases is inadequately implemented in practice due to underlying issues such as outdated technical verification methods and lax enforcement by medical institutions. To address these challenges, it is recommended to establish a multi-dimensional and systematic regulatory framework, and comprehensively promote precise verification technologies such as facial recognition, which can provide academic references and practical pathways for strengthening the security of medical insurance funds and improving the real-name policy.
Key words
fraudulent medical services using others' identities /
real-name medical treatment /
fund supervision /
healthcare fraud /
facial recognition
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References
[1] 国家医疗保障局.我医保卡里的钱到底能不能给亲人买药?[EB/OL].(2024-05-08)[2025-10-22].https://www.nhsa.gov.cn/art/2024/5/8/art_52_12623.html.
[2] 李阳,周婵.冒用他人身份信息就诊的风险及防控——以成都市某三甲医院为例[J].中国卫生法制,2018,26(2):68-71.
[3] 张广. 关于冒用他人身份就诊的法律问题探析[J].中国卫生人才,2015(12):38-40.
[4] 孙佳佩,周守君,朱星瑶.医保异地就医政策下三级医院的现状与对策——以某三甲肿瘤医院为例[J].江苏卫生事业管理,2022,33(3):355-356.
[5] 刘畅,王宇菲.京津冀异地就医直接结算政策执行偏差问题研究[J].中国医院,2023,27(1):7-10.
[6] 侯慧玉,张华星,王建斌,等.医保参保人就医行为对基金管理的挑战与思考[J].医学与哲学,2025,46(4):56-59.
[7] 严琴,詹新徽,杨保燕.完善医保监管制度杜绝冒名就医行为[J].农垦医学,2016,38(5):478-480.
[8] 王爽. “互联网+医疗”医保支付对居民就医行为的影响研究[D].呼和浩特:内蒙古财经大学,2024.
[9] 冯姝,张静,冯滔,等.利益相关者视角下实名制诊疗的有效推进路径[J].卫生软科学,2021,35(11):15-18.
[10] 李忠,欧阳铨球,张海峤,等.以推动职能核卡为契机提升线上医保基金监管质效[J].中国医疗保险,2024,205(1):112-116.
[11] 张洪宇,康正,张婷,等.黑龙江省和山东省公众医保基金骗保行为的原因分析[J].医学与社会,2022,35(11):135-139.
[12] 殷立昇,马明丽,邢建亮,等.典型地区医保基金智能监管经验做法及借鉴[J].现代管理,2023,13(12):1616-1622.
[13] 何泽溟.医保惠民连连看|就医也能“刷脸”!吉林省2800家定点医药机构实现医保刷脸支付[N].吉林日报,2025-03-21(4).
[14] 袁理娜,张欣燕,宋小宛,等.职工医保门诊统筹政策对患者就医行为的影响——基于因果森林模型[J].中国卫生统计,2024,41(6):932-936.
[15] 蔡呈曦. 杭州市数字赋能医保智慧监管体系建设的路径与成效分析[J].中国医疗保险,2021,155(8):26-29.
[16] 杭州市医疗保障局.2024年法治政府建设年度报告[R].2025.
[17] 人民网-湖南频道.湖南祁阳:创新智慧医保监管模式守好群众“救命钱”[EB/OL].(2025-07-30)[2025-10-22].http://hn.people.com.cn/n2/2025/0730/c356887-41307846.html.
[18] 国家医疗保障局. 2024年全国医疗保障事业发展统计公报[EB/OL].(2025-07-14)[2025-10-22].https://www.nhsa.gov.cn/art/2025/7/14/art_7_17248.html.
[19] 马树娟.织牢医保基金监管网[N].法治日报,2025-11-12(001).
[20] 国家医疗保障局.守护医保基金安全靠大家！各地医保部门深入推进基金监管集中宣传月活动(三)[EB/OL].(2024-06-26)[2025-10-22].http://www.nhsa.gov.cn/art/2024/6/26/art_14_13057.html.
