In a recent investigation by China’s National Healthcare Security Administration’s big data center, significant fraudulent activities were uncovered in a pharmacy located in Harbin, Heilongjiang Province. The probe revealed that insured individuals were purchasing an unusually high volume of medications from this pharmacy. Consequently, a special task force was dispatched to conduct an in-depth examination of the situation. The investigation revealed that four pharmacies were involved in the creation of thousands of handwritten fake prescriptions, amounting to over 100 million yuan.

What new information has surfaced regarding this investigation? What are the implications of the issues uncovered? And what challenges remain in safeguarding healthcare insurance funds? Let’s delve into these pressing questions.

In response to the National Healthcare Security Administration’s findings, Harbin has initiated a citywide crackdown on pharmacy-related fraud. As a result, the four implicated pharmacies have had their healthcare service agreements suspended and have been ordered to cease operations while cooperating with the investigation. The local police have filed criminal cases against all involved, freezing approximately 62.23 million yuan in defrauded healthcare funds. A total of 51 individuals have faced legal repercussions, including 13 detained for criminal charges, 15 placed under judicial supervision, and 3 administratively detained. Moving forward, Harbin will continue its thorough investigation and ramp up supervision across the industry.

Can you describe the process of this special inspection? Has it concluded?

Xu Youlong, Director of the Regulatory Affairs Department of the Fund Supervision Division at the National Healthcare Security Administration, stated that substantial preliminary work was conducted to clarify this case. This included reaching out to numerous patients, visiting 14 leading hospitals, having around 300 doctors evaluate nearly 50,000 prescriptions, and performing data analysis to identify suspicious activities. The investigation uncovered that the pharmacies had fabricated a large number of prescriptions for special medications and had led insured individuals to purchase medications under false pretenses, constituting healthcare fraud. The National Healthcare Administration has coordinated with the Ministry of Public Security to establish a dedicated task force to assist in recovering defrauded funds and enforce administrative penalties against those responsible.

As the investigation reaches a conclusion, efforts will shift towards supporting law enforcement for a deeper analysis of the case.

Additionally, the National Healthcare Administration is guiding local agencies to apply lessons learned from this case, conducting extensive searches in Harbin and Heilongjiang Province to combat similar fraud. Nationwide, any instances of pharmacies producing fake prescriptions will be swiftly addressed.

What challenges were encountered during this inspection, and are they common across the board?

Xu Youlong identified three main difficulties faced during the inspection:

1. **Mix of Real and Fake Prescriptions**: The four pharmacies produced counterfeit prescriptions that often aligned with patients’ actual illnesses. For example, prescriptions for osimertinib tablets used to treat non-small cell lung cancer were found to correspond to real patients’ conditions, making it difficult to identify issues without thorough investigation. After consulting with hospitals, it became evident that the pharmacies were overprescribing medications to manipulate the system.

2. **Complexity of Involved Parties**: The fraudulent scheme included not only pharmacy staff but also pharmaceutical representatives and a handful of doctors, along with a vast number of insured individuals. This complexity necessitated extensive outreach and considerable human and material resources to fully uncover the extent of the fraud.

3. **Destruction of Evidence and Resistance**: Some pharmacies were uncooperative during the investigation, refusing to provide prescriptions and even attempting to delete surveillance footage, complicating the inspection process.

What motivations drive pharmacies and representatives to engage in fraud?

Xu Youlong explained that the pharmacies primarily dealt with high-value medications for special outpatient treatments, where pharmaceutical costs are considerable and reimbursement rates are also high. Some pharmacies directly fabricated prescriptions to siphon off healthcare funds, others prescribed more medications than needed to inflate their earnings, while some engaged in organized schemes with patients to purchase excess medications. Additionally, there are cases of pharmaceutical representatives resorting to fraudulent practices to boost sales, and certain medical staff may overprescribe as a means of earning illicit income.

Why was the fraud not detected during routine inspections?

Xu Youlong highlighted that while there are regulatory measures in place, such as defining patients, medical institutions, responsible physicians, prescriptions, and pharmacy management, not all pharmacies comply strictly. The investigation revealed a comprehensive chain of deception to evade regulations, including purchasing blank prescription paper, forging hospital and physician seals, falsifying patient information, and creating entirely fictitious illnesses. Local healthcare departments had conducted inspections in the past, but these lacked depth and thoroughness, indicating a need for improved vigilance and understanding of complex fraudulent schemes.