Targeting "gold-selling sales," medical insurance fund supervision continues to intensify and upgrade

21st Century Economic Report reporters Han Liming and intern Jiang Yutong

In recent days, the National Medical Insurance Administration has disclosed two bribery cases in the pharmaceutical sales sector. From Tao Moumou’s long-term payment of “kickbacks” to relevant doctors to boost sales of the nasal spray he distributed, to Zhang Moumeng’s payments of kickbacks and benefits to obstetric and gynecological department heads and other medical staff based on the number of prescriptions to increase sales of Compound Huangbai Liquid and enhance personal promotion profits, the cases expose the chaotic phenomenon of “bribery in sales” in the pharmaceutical field.

Bribery in the pharmaceutical sales sector essentially “buys out” doctors’ prescribing rights through improper benefits, disrupting the normal order of diagnosis and treatment, leading to a deviation of pharmaceutical sales logic from actual clinical value, tilting towards high rebates and high kickbacks. Although judicial authorities have punished the cases, the issue of inflated drug prices reflected by the cases still exists. If not addressed promptly, the inflated drug prices will continue to infringe upon patients’ legitimate rights and interests, and will also cause unreasonable losses to the medical insurance fund.

The medical insurance fund is the “money for medical treatment and life-saving” of the people, and its regulated use directly relates to the sustainable operation of the medical insurance system. Data shows that in 2025, China’s basic medical insurance fund (including maternity insurance) had a total income of 35,873.11 billion yuan and total expenditure of 30,009.38 billion yuan. Thanks to the continuous strengthening of regulatory efforts, the national medical insurance system recovered 34.2 billion yuan of illegal medical insurance funds in 2025.

Industry insiders told 21st Century Economic Report reporters that compared to the phenomenon of inverted growth in medical insurance fund income and expenditure in 2024, the income growth rate of medical insurance in 2025 has exceeded the expenditure growth rate. Behind this change is the improvement in the efficiency of the use of medical insurance funds and the continuous optimization of regulatory levels, laying a foundation for the long-term sustainable operation of the medical insurance system, and indicating that the supervision of the medical insurance fund will continue to deepen and solidify.

Image source: National Medical Insurance Administration official WeChat account

Cutting Off the Kickback Interest Chain

On March 23, the National Medical Insurance Administration disclosed that the People’s Court of Echeng District in Ezhou City, Hubei Province, publicly tried the bribery case of Tao Moumou against non-state personnel using a simplified procedure in August 2025.

After investigation, it was found that the defendant Tao Moumou, to increase the sales of the “high osmotic seawater nasal spray” distributed by his company, communicated with relevant doctors at Ezhou Central Hospital, implying that doctors should prescribe this nasal spray more to patients and clearly stating the kickback settlement standards: 30 yuan per unit for the 30ml nasal spray and 45 yuan per unit for the 125ml nasal spray, settled regularly based on the actual amount prescribed by the doctors. From 2016 to 2024, over eight years, Tao Moumou cumulatively bribed relevant prescription doctors a total of 465,000 yuan.

The court determined that Tao Moumou’s actions constituted the crime of bribing non-state personnel. Considering the circumstances of the crime, confession attitude, and return of stolen goods, he was ultimately sentenced to four months of detention and fined 10,000 yuan, while his illegal gains of 165,000 yuan were confiscated and turned over to the national treasury.

On March 24, the National Medical Insurance Administration disclosed another bribery case involving a larger amount and more personnel related to drug sales.

Defendant Zhang Moumeng promoted Compound Huangbai Liquid by finding Sun Moumei, the then head of the obstetrics and gynecology department at Shanhaiguan People’s Hospital in Qinhuangdao City, promising to pay kickbacks based on the number of prescriptions for the use of the drug in obstetrics and gynecology. Between August 2013 and January 2023, Zhang Moumeng paid Sun Moumei over 156,900 yuan in kickbacks. Additionally, Zhang Moumeng targeted the dermatology department of the hospital, where he paid dermatologists Wang Mouhui and Zhang Mouwen a total of 18,300 yuan in kickbacks from October 2014 to January 2023.

Furthermore, to facilitate the statistics on the amount of kickbacks paid, Zhang Moumeng asked Zhang Mousong, the director of the outpatient pharmacy of the hospital, to help him tally the number of prescriptions for Compound Huangbai Liquid from relevant departments and doctors, promising to pay Zhang Mousong benefits based on the statistics. From November 2014 to July 2023, he successively paid Zhang Mousong benefits exceeding 25,000 yuan.

The court ruled that Zhang Moumeng committed the crime of bribery, sentencing him to ten months in prison and a fine of 10,000 yuan; for bribing non-state personnel, he was sentenced to six months in prison and fined 10,000 yuan; for multiple crimes, the sentences were consolidated to a total of one year in prison, with a probation period of one year and six months, and a fine of 20,000 yuan.

Image source: National Medical Insurance Administration official WeChat account

In fact, the chaotic phenomenon of “bribery in sales” in the pharmaceutical field occurs frequently. From the industry’s perspective, in a normal diagnostic system, doctors’ prescribing rights are based on professional decisions made in consideration of the patient’s condition and the clinical value of pharmaceutical products, while bribery distorts this public power into a tradable “commodity,” twisting the market competition logic of pharmaceutical products—product competitiveness no longer depends on efficacy and cost-effectiveness, but rather on the level of rebate ratios and kickback amounts.

This model, on one hand, diverts prescribing rights from professional attributes, disrupting the normal order of diagnosis and treatment, leading high-rebate drugs to gradually dominate prescriptions, while patients’ reasonable medication needs are relegated to a secondary position; on the other hand, the flow of medical insurance funds deviates from the original intention of “ensuring basic and key needs,” with large amounts of funds invested in high-rebate and high-priced drugs and examination items, resulting in fund waste and violating the principle of fairness in the medical insurance system.

To curb such chaos from the source, the National Medical Insurance Administration established a price procurement credit evaluation system as early as 2020, conducting integrity ratings for enterprises with prominent issues of bribery, sales with kickbacks, and others as adjudicated by the courts or investigated by relevant departments, and implementing constraints such as restrictions on online listings and distribution.

In the next step, the National Medical Insurance Administration will guide local medical insurance bureaus to properly conduct integrity ratings according to regulations, urge enterprises to take timely measures to correct dishonest behaviors, and implement relevant constraints to better safeguard the security of the medical insurance fund, cutting off the survival soil of bribery in sales from the source.

Strengthening the Safety Defense Line of the Medical Insurance Fund

In response to bribery in pharmaceutical sales and irregular use of medical insurance funds, regulatory authorities in China have continuously intensified oversight efforts, constructing a comprehensive, multi-level regulatory system to precisely crack down on various illegal and irregular activities.

Data shows that in 2025, the national medical insurance system recovered a total of 34.2 billion yuan of medical insurance funds, of which 27.8 billion yuan was recovered through medical insurance management review and verification. A total of 1,626 fraudulent medical insurance institutions were identified, and 1,678 cases were referred to judicial authorities. Joint investigations with public security agencies led to 3,776 medical insurance cases, resulting in the arrest of 10,357 criminal suspects. The intelligent regulatory subsystem recovered losses of 3 billion yuan in medical insurance funds.

The construction of a drug and consumables traceability system has been accelerated. The National Medical Insurance Information Platform has accumulated 100.182 billion sales trace codes from designated medical institutions, with 1.0273 million institutions connected. Relying on the national medical insurance service platform, a “medical insurance drug and consumables traceability information inquiry” function has been launched, with over 5 million inquiries per day. Utilizing trace codes to combat the resale of “refunded drugs,” over 240,000 suspicious leads have been verified, and 695 cases have been cracked in cooperation with public security agencies, leading to the arrest of 2,576 professional fraudsters.

Entering 2026, the regulatory efforts for the medical insurance fund will further escalate. According to the “Notice on the Work of Medical Insurance Fund Supervision for 2026” issued by the National Medical Insurance Administration, targeted rectification of prominent issues in medical insurance fund management will continue in 2026; comprehensive promotion of quality improvement in unannounced inspections will be implemented.

Since March 2026, many regions have taken the lead in deploying self-inspection and correction work for the illegal and irregular use of medical insurance funds by designated medical institutions.

Among them, the Pudong New District of Shanghai held a 2026 medical insurance work meeting emphasizing a focus on drug trace codes, abnormal assessment levels for long-term care insurance, “abnormal hospitalizations,” “excessive prescriptions,” “imaging departments,” “maternity insurance,” “rehabilitation, therapy,” and “medical assistance,” continuing targeted rectification of prominent issues in medical insurance fund management, and reinforcing the fund usage responsibility of designated institutions.

The Health Insurance Bureau of Xingan League in Inner Mongolia also held a meeting, requiring all designated medical institutions to deepen self-inspection and correction, focusing on issues such as overdiagnosis and treatment, conducting thorough investigations item by item, rigorously addressing problems, establishing problem accounts, managing them by closing out issues, and timely returning illegal medical insurance funds and expenses involving individual payments by the public. There should be further strengthening of communication and coordination with higher-level departments to resolve encountered difficulties, using self-inspection and correction work as an opportunity to improve the long-term management mechanism of designated medical institutions for medical insurance.

Additionally, many regions have broadened regulatory channels through public solicitation of leads and enhanced social supervision. The Hunan Provincial Medical Insurance Bureau recently issued a notice soliciting leads on issues related to illegal and irregular use of medical insurance funds, focusing on leads from designated medical institutions, insured individuals, professional fraudsters, medical insurance agencies, and administrative and local industry departments. Taking designated medical institutions as an example, in addition to regulatory focuses such as duplicate billing, split billing, excessive billing, overdiagnosis, and the falsification of medical imaging materials like CT, X-ray, MRI, and ultrasound, inducing hospital admissions and impersonating medical treatment are also included in the scope of solicitation.

It is noteworthy that the 2026 medical insurance fund flight inspection in Gansu Province has fully commenced. It is reported that the Gansu Provincial Medical Insurance Bureau has introduced five third-party professional institutions, forming 16 inspection teams to conduct comprehensive flight inspections across all 14 cities and states and 2 overall planning areas in the province. Using a “triangular iron” professional team and intelligent regulatory means, strict investigations into violations in the use of medical insurance funds will solidify the safety defense line for the public’s “medical treatment money.” This inspection covers 145 designated medical institutions, 267 designated retail pharmacies, and 16 medical insurance agencies, with a focus on tertiary hospitals and private medical institutions.

The level of regulatory legalization has also reached a new height. Starting from April 1, the “Implementation Rules for the Supervision and Management of Medical Insurance Fund Usage” (hereinafter referred to as “Implementation Rules”) officially came into effect. Tongli Law Firm in Shanghai published an article stating that as an important supporting regulation for the “Supervision and Management of Medical Insurance Fund Usage,” the Implementation Rules systematically refined and supplemented contents on fund usage, supervision and inspection, determination of violations, legal responsibilities, and coordination between criminal and administrative proceedings based on summarizing recent years of regulatory practice and incorporating reform achievements, marking a new stage of more precise, standardized, strict, and coordinated legalization in the supervision of medical insurance funds in China.