The medical insurance fund is the "money for seeking medical care" and the "life-saving money" for the people, directly impacting their immediate interests. It is crucial for the healthy and sustainable development of the healthcare security system, as well as vital to the long-term stability and prosperity of the nation. Since the 18th National Congress of the Communist Party of China, the Party Central Committee—led by Comrade Xi Jinping—has placed great emphasis on safeguarding the integrity of the medical insurance fund. General Secretary Xi Jinping has repeatedly issued important instructions and directives aimed at strengthening oversight of the medical insurance fund, while the Third Plenary Session of the 20th Central Committee of the CPC laid out clear guidelines for reinforcing this oversight. In 2024, the Supreme People's Court has firmly implemented the spirit of General Secretary Xi Jinping’s key instructions and directives, along with the central government’s strategic plans, fully leveraging its criminal justice functions to rigorously prosecute, in accordance with the law, crimes involving fraud and misuse of medical insurance funds. This proactive approach effectively protects the integrity of the medical insurance fund and upholds the public’s legitimate right to access high-quality healthcare services. First, develop guiding principles. Leading the drafting of the "Guiding Opinions of the Supreme People's Court, Supreme People's Procuratorate, and Ministry of Public Security on Several Issues Concerning the Handling of Criminal Cases Involving Fraudulent Medical Insurance Claims," which clearly outlines the criteria for criminal conviction and sentencing, legal application, policy considerations, case-handling requirements, and relevant institutional mechanisms. Second, we will launch a targeted remediation campaign. Together with the National Healthcare Security Administration and other relevant departments, we will carry out a special crackdown on illegal and irregular activities involving medical insurance funds in 2024, while simultaneously coordinating with courts nationwide to launch their own targeted efforts against such issues this year. Third, strictly punish healthcare fraud crimes in accordance with the law. People's courts at all levels have strictly punished healthcare fraud crimes in accordance with the law, focusing particularly on targeting behind-the-scenes organizers and professional fraudsters. In 2024, courts across the country concluded 1,156 healthcare fraud cases involving 2,299 individuals in the first instance—representing a year-on-year increase of 131.2% in case closures. This effort helped recover more than 402 million yuan in losses to the healthcare insurance fund. Fourth, issuing judicial recommendations. Based on thorough research, the system systematically analyzes the root causes behind the frequent and widespread occurrence of medical insurance fraud crimes, and proposes targeted measures to strengthen oversight of medical insurance funds. As a result, the "Supreme People's Court Judicial Recommendation on Enhancing Medical Insurance Fund Supervision and Safeguarding the Security of Medical Insurance Funds" has been issued. Fifth, strengthen publicity and awareness-raising efforts. A press conference was held to release typical cases of criminal activities involving healthcare fraud, in line with the law. News media were invited to conduct interviews on these cases, shedding light on the illicit "return-to-China drug" black market chain and other related scandals—thus generating widespread, enthusiastic publicity and fostering a positive, constructive public response.

To fully leverage the "address one case, improve an entire area" impact of these exemplary cases, the Supreme People's Court has carefully selected four landmark cases from medical insurance fraud prosecutions handled by people's courts at all levels across the country. These cases highlight the court’s commitment to strict legal enforcement, demonstrating its unwavering determination and proactive measures in combating medical insurance fraud. At the same time, they underscore the judiciary’s critical responsibility and dedication to safeguarding the security of medical insurance funds and upholding the legitimate healthcare rights and interests of the public.

Next, the People's Courts will thoroughly implement the important instructions and directives of General Secretary Xi Jinping, as well as the central government’s deployment requirements, and vigorously advance efforts to combat and address healthcare insurance fraud crimes, firmly safeguarding the security of medical insurance funds.

The fraud case involving defendants Ai Mouzhong and others

I. Summary of the Facts

In September 2016, the defendant Ai Mouzhong took the lead in funding the establishment of Datong City Chengqu Hospital Co., Ltd. in Shanxi Province, also serving as its legal representative. By early 2018, the hospital had become a designated medical institution eligible for reimbursement under the national medical insurance program. In December 2018, the hospital was renamed Datong City Pingcheng District Hospital Co., Ltd., with Ai Mouyu appointed as the new legal representative—though Ai Mouzhong remained the actual controller. Ai Mouzhong repeatedly convened meetings with Ai Mouyu, Zhang Mocai, Li Mou, Niu Mopeng, Zhang Moguo, Zhao Mou, and others to discuss their plan to fraudulently obtain funds from the national medical insurance system. Under this scheme, the hospital actively recruited patients from surrounding counties and districts, encouraging both its own staff and their families to be admitted as inpatients. The hospital’s two key departments—the Internal Medicine and Orthopedics departments—played central roles, while other departments provided supportive assistance. To inflate costs, the hospital employed various deceptive practices, including artificially inflating drug purchase prices, repeatedly recording the same medications, exaggerating clinical prescriptions and diagnostic tests, falsely reporting bed occupancy rates, and even leaving beds empty while still billing for them. These tactics enabled the hospital to significantly overstate and fabricate patient expenses, leading to the creation of fake medical records. Ultimately, the hospital submitted these falsified data to the medical insurance center, successfully defrauding the national medical insurance fund. By the end of 2020, the hospital had overstated its claims by more than 9.7 million yuan, of which over 2 million yuan remained unpaid—a clear case of attempted fraud.

II. Ruling Outcome

This case was tried in the first instance by the Intermediate People's Court of Datong City, Shanxi Province, and reviewed in the second instance by the Higher People's Court of Shanxi Province; it has now become legally binding.

The People's Court, after careful deliberation, found that the defendants Ai Mouzhong and others, with the intent to illegally obtain property, systematically inflated hospitalization costs by artificially increasing drug purchase prices, repeatedly entering drugs into inventory, exaggerating clinical medication and examination fees, falsely reporting bed occupancy rates, and maintaining vacant beds. They also fabricated fake medical records and submitted these fraudulent data to the medical insurance center, collectively defrauding the medical security fund in an especially large amount. Their actions thus constitute the crime of fraud. Based on the specific facts of each defendant’s crimes, as well as the nature and severity of their offenses, the court handed down the following sentences: Defendant Ai Mouzhong was sentenced to 13 years and 6 months in prison, along with a fine of RMB 500,000; Defendant Ai Mouyu received 11 years in prison and a fine of RMB 200,000; Defendant Zhang Moucai was sentenced to 10 years and 6 months in prison, along with a fine of RMB 150,000; Defendant Li Mou was sentenced to 10 years in prison and fined RMB 100,000; Defendant Zhang Mougou was given 10 years in prison and ordered to pay a fine of RMB 100,000; Defendant Niu Moupeng was sentenced to 10 years in prison and fined RMB 100,000; and Defendant Zhao Mou was sentenced to 4 years in prison, accompanied by a fine of RMB 30,000. (Other sentencing details omitted.)

III. Typical Significance

This case is a prime example of how private hospitals and their staff fraudulently obtained medical insurance funds by inflating drug purchase prices, repeatedly entering drugs into inventory, falsely reporting clinical medication usage and examination fees, overstating the number of hospital beds, and leaving beds unoccupied. Private hospitals play a crucial role in strengthening healthcare capacity and ensuring access to medical treatment and medications for the public. However, some private hospitals and their employees, driven by illicit gains, have resorted to deceptive practices to siphon off national medical insurance funds—actions that gravely undermine the sustainable and healthy development of the healthcare security system and thus warrant strict legal punishment. According to the "Guiding Opinions on Several Issues Concerning the Handling of Criminal Cases Involving Medical Insurance Fraud," when multiple individuals are involved, each suspect should be treated differently based on the specifics of their crimes, the nature of their actions, the severity of the offenses, and the extent of harm caused to society. Additionally, their respective roles and contributions within the criminal network—including whether they played a primary or secondary part—must be carefully considered during sentencing. In this case, the People’s Court has firmly upheld a criminal policy that balances leniency with severity. The six defendants, including Ai Mouzhong, who played a central role in the scheme, were meted out harsher penalties under the law, receiving prison sentences exceeding ten years. Meanwhile, Zhao Mou, who bore a lesser responsibility and even turned himself in voluntarily, received a more lenient sentence as warranted by law. This approach not only effectively addresses the crime of medical insurance fraud but also ensures that the judicial process achieves optimal outcomes in political, legal, and societal terms.

Defendant Du Moujun's Fraud Case

I. Summary of the Facts

Since August 2023, the defendant Tao Mouyun has exploited the medical insurance reimbursement policy to illegally profit by reselling medications. He repeatedly visited multiple medical institutions, using his medical insurance card to obtain excessive or fraudulent prescriptions for various drugs, which he subsequently sold at discounted prices to others. Despite having no prior history of cardiovascular, cerebrovascular, psychiatric, or asthma-related conditions, Tao Mouyun fraudulently prescribed drugs such as dapagliflozin tablets, Naoxintong capsules, and dopasizine tablets—totaling over 220,000 yuan in value. ” In various ways, they attracted a large number of middle-aged and elderly patients covered by medical insurance to receive inpatient treatment. They employed tactics such as first issuing hospitalization permits to initiate admission procedures, followed by ordering diagnostic tests—or even issuing test requisitions upfront while delaying the actual testing until after the patient had already been admitted. This approach ensured that all patients eager for hospitalization were promptly admitted, where they received basic medical services like medication, nebulization, and intravenous infusions. Meanwhile, high-margin antibiotics and other lucrative drugs were prescribed liberally. To ensure these individuals met the eligibility criteria for hospitalization and to evade detection, Du Moujun instructed or tacitly approved doctors, medical assistants, and laboratory technicians to collaborate closely. Together, they manipulated key medical reports—such as blood test results and DR imaging studies—altering them to make it appear as though the patients qualified for inpatient care. As a result, the associated medical expenses and test fees incurred during hospitalization were fraudulently submitted for reimbursement through the national health insurance system, ultimately siphoning off over 3.9 million yuan from the state’s medical security fund.

II. Ruling Outcome

This case was tried in the first instance by the Shapingba District People's Court of Chongqing and reviewed in the second instance by the No. 1 Intermediate People's Court of Chongqing, and has now become legally binding.

The People's Court, after deliberation, found that the defendant, Du Moujun, as the actual controller of a designated medical institution, instructed staff to commit fraud by falsifying medical test data and fabricating false medical records. This allowed patients who did not require hospitalization to be admitted for treatment, thereby illegally obtaining substantial amounts of medical insurance funds—amounting to an especially large sum. Consequently, his actions constitute the crime of fraud. Accordingly, the court sentenced Du Moujun to 12 years of imprisonment and imposed a fine of RMB 500,000. (Other sentencing details omitted.)

III. Typical Significance

This case is a prime example of how the owner of a designated medical institution fraudulently obtained Medicare funds by tampering with medical documents, such as inspection reports. According to the "Guiding Opinions on Several Issues Concerning the Handling of Criminal Cases Involving Medicare Fraud," if a designated medical institution, with the intent to illegally obtain funds, forges, alters, conceals, modifies, or destroys medical records, medical certificates, accounting documents, electronic information, test reports, or other relevant materials to deceive the medical insurance fund into making payments, those who organize, plan, or carry out such activities shall be convicted and punished for fraud under Article 266 of the Criminal Law. In this case, the defendant, Du Mojun, exploited the designated hospital he operated by manipulating test reports, medical records, and other documents to siphon off Medicare funds—amounting to an exceptionally large sum. Not only did his actions violate professional ethics and the terms of the Medicare designated service agreement, but they also constituted a criminal offense. As a result, the People’s Court handed down a severe legal punishment against him for the crime of fraud.

Defendant Dai Moushou Case of Concealing and Hiding Proceeds of Crime

I. Summary of the Facts

From June 2020 to December 2021, the defendant Dai Moushou, operating without the necessary licenses such as a drug distribution permit and business license, purchased and sold "medically insured drug repurchase products" by connecting with suppliers and buyers via WeChat. He also rented a warehouse as a storage facility and hired others to handle packaging and shipping of the medications. Investigations revealed that Dai Moushou sold the acquired "medically insured drug repurchase products" to Ji Mouzhou and Peng Mou, collecting over 3.4 million yuan in total. Following the case’s discovery, public security authorities seized 10,416 boxes of the implicated drugs.

Starting in July 2022, the defendant Dai Moushou, without the necessary licenses such as a pharmaceutical business permit or a business license, engaged in the acquisition and sale of "medical insurance-reclaimed drugs" by contacting suppliers and buyers via WeChat. He also rented a facility and hired others to handle tasks like packaging and shipping the medications. Investigations revealed that Dai Moushou purchased "medical insurance-reclaimed drugs" from individuals including Wang Mouxing, paying over 180,000 yuan in total, and subsequently sold these drugs to Zhai Mougang, earning 570,000 yuan. Following the case's discovery, public security authorities seized 10,133 boxes of the implicated drugs.

II. Ruling Outcome

This case has been tried by the People's Court of Fuliang County, Jiangxi Province, and has now become legally binding.

The People's Court, after deliberation, found that the defendant Dai Moushou knowingly and illegally acquired and sold drugs obtained through fraudulent use of medical insurance benefits—actions that constituted a serious offense. Consequently, he was convicted of the crime of concealing or hiding proceeds of crime. As a result, the court sentenced Dai Moushou to six years in prison and imposed a fine of RMB 120,000. (Other sentencing details omitted.)

III. Typical Significance

This case is a landmark example of the People's Court strictly enforcing the law to crack down on crimes involving the resale of drugs obtained through fraudulent medical insurance schemes. In recent years, the illegal activities of acquiring and selling medications purchased using fraudulent claims under the medical insurance program have become increasingly severe. Some criminals have formed organized crime groups, employing non-contact methods to illegally profit from reselling these fraudulently obtained drugs. Such actions not only result in substantial financial losses to the medical insurance fund but also lead to widespread waste, as many drugs are improperly stored or even spoiled. What’s more, some of these deteriorated medications end up re-entering the market, posing serious risks to public health—and thus highlighting the critical need for effective measures to combat such fraudulent practices. According to Article 13 of the "Interpretation by the Supreme People's Court and the Supreme People's Procuratorate on Several Issues Concerning the Application of Law in Handling Criminal Cases Related to Drug Safety," anyone who knowingly purchases or sells drugs acquired through fraudulent medical insurance claims—provided the amount involved exceeds 50,000 yuan—shall be prosecuted and punished under Article 312 of the Criminal Law for the crime of concealing or hiding criminal proceeds. This principle is further reinforced in the "Guiding Opinions on Handling Criminal Cases Related to Fraudulent Medical Insurance Claims." In this case, the defendant, Dai Moushou, was clearly aware that the drugs he acquired were obtained through fraudulent medical insurance claims. Despite this knowledge, he repeatedly engaged in non-contact transactions to buy and sell these illicitly sourced medications. The People's Court, after careful legal review, determined that his actions constituted the crime of concealing or hiding criminal proceeds, and given the severity of the circumstances, sentenced him to six years in prison. This verdict underscores the court’s unwavering commitment to addressing the entire chain of criminal activity associated with fraudulent medical insurance claims.

The fraud case involving defendants Tao Mouyun and Xu Moxia

I. Summary of the Facts

Since August 2023, the defendant Tao Mouyun has abused the medical insurance reimbursement policy to illegally profit from reselling medications. He repeatedly visited multiple medical institutions using his医保 card to obtain excessive or fraudulent prescriptions for various drugs, which he then sold at low prices to others. Despite having no prior history of cardiovascular, cerebrovascular, psychiatric, or asthma-related conditions, Tao Mouyun fraudulently prescribed drugs such as dapagliflozin tablets, Naoxintong capsules, and dopasizine tablets—totaling over 220,000 yuan in value.

Meanwhile, on November 2, 2023, the defendant Tao Mouyun met the defendant Xu Mouxia near the entrance of a hospital. At Xu Mouxia's instruction, Tao Mouyun fraudulently obtained prescriptions for various medications—including Naoxintong Capsules, Shensong Yangxin Capsules, and Dapagliflozin Tablets—from multiple medical institutions using a medical insurance card, totaling over 80,000 yuan in value. Despite knowing that these drugs were acquired through Tao Mouyun's fraudulent use of the medical insurance system to obtain illegal profits, Xu Mouxia still purchased them at a significantly reduced price.

II. Ruling Outcome

This case was heard by the People's Court of Liuhe District, Nanjing City, Jiangsu Province, and has now become legally binding.

The People's Court, after hearing the case, found that the defendant Tao Mouyun, with the intent to illegally obtain property, used deceitful tactics—fabricating facts and concealing the truth—to fraudulently acquire a substantial amount of national medical insurance funds, thereby constituting the crime of fraud. Additionally, the court determined that the defendant Xu Mouxia instructed others to exploit the medical insurance system for fraudulent purposes, purchasing medications and subsequently engaging in illegal acquisition of these drugs on a significant scale, which also constituted the crime of fraud. Accordingly, defendant Tao Mouyun was sentenced to three years and two months in prison, along with a fine of RMB 30,000, for the crime of fraud; while defendant Xu Mouxia received a sentence of one year and seven months in prison, accompanied by a fine of RMB 20,000. (Other sentencing details omitted.)

III. Typical Significance

This case is a prime example of an insured individual fraudulently obtaining medical insurance funds. According to relevant laws and regulations, insured persons are prohibited from exploiting their access to healthcare benefits to resell medications or accept cash rebates, in-kind gifts, or any other illegal gains. If an individual engages in such activities—reselling drugs, accepting cash or goods, or seeking other illicit profits while improperly using their healthcare benefits—they will be ordered by the medical insurance administrative authority to rectify their actions. If this results in financial losses to the medical insurance fund, the individual will be required to repay the stolen amount. For those who are insured, their eligibility for online medical expense settlements may even be suspended for anywhere between 3 and 12 months. Moreover, if an individual commits the aforementioned acts with the explicit intent to defraud the medical insurance fund, causing financial harm to the system, they will face fines ranging from two to five times the amount fraudulently obtained, imposed by the medical insurance administrative authority. Additionally, if the perpetrator’s actions meet the criteria outlined in Article 266 of the Criminal Law—specifically, if the fraud is aimed at illegally appropriating medical insurance funds—the offender will be prosecuted and punished as a criminal under the charge of "fraud." In this case, the defendant Tao Mouyun, as an insured individual, exploited her entitlement to healthcare benefits by reselling medications for personal gain, thereby securing unlawful profits. As a result, the People’s Court handed down a three-year-and-two-month prison sentence for fraud, in accordance with the law. Similarly, the defendant Xu Mouxia, who instructed others to misuse Medicare cards to obtain prescription drugs for illegal resale, also committed the crime of fraud. The People’s Court emphasizes that the medical insurance fund represents a shared, universally beneficial resource—a finite asset available to all citizens. As beneficiaries of government healthcare policies, insured individuals not only have the right to legitimately and accurately claim their medical benefits but also bear the responsibility to safeguard the fund’s long-term health and sustainability. The court makes it clear: fraudulent behavior aimed at misappropriating medical insurance funds will never be tolerated or overlooked.