台灣健保詐欺量刑標準之實證研究
Other Title
The Empirical Research of the Sentencing Standard for the Fraud of National Health Insurance in Taiwan
Journal
月旦法學雜誌
Journal Volume
242
Start Page
41
End Page
62
Date Issued
2015-07
Author(s)
Abstract
保險詐欺獲利高而風險和成本低，此種犯罪涉及醫療專業，常與健保浪費無法區分，審查與舉證更加困難。醫師是受社會大眾敬重之職業，若利用專業醫療知識進行健保詐欺，則屬白領犯罪。全民健康保險開辦已逾二十年，為強制性社會保險，其主要宗旨為全民納保、普遍繳費、就醫無礙。以往詐欺保險公司之詐欺行為，近年來逐漸蔓延蠶食健保給付領域，詐領方法也不斷推新。八十九年至九十六年的研究發現司法判決實難嚇阻醫療詐欺，因為平均刑期約僅十個月，且緩刑機會比一般詐欺案件高。年發生件數無顯著差異，但再犯占百分之八十六•六。簡言之，我國司法在審理健保詐欺案件時，的確對具醫師身分的被告較為寬容。本研究擬分析九十七年至一百年地方法院對醫療詐欺之判決，並與先前相關研究與判決結果比較與分析，以探討各種處分方式（起訴、緩起訴或不起訴等）是否相當或足以嚇阻醫療詐欺，以及探討地方法院判決之量刑標準是否合理與客觀，進而提出修法建議與防制對策，防止健保詐欺弊情擴散蔓延，避免健保資源被不當浪費或詐領，以保障全民健保能永續經營。
The results of this study shows that there is no objective standard for probation judgments, judgments and fines are also without objective criteria, although the sentenced days has positive correlation with the sum of fraud, but still the high variability existed for sentencing, depending on the freedom of individual judges, leading to no objective standard for sentencing. Total cases for health care fraud between 2008 and 2011 from district courts are only 97 with total number of 184 defendants, this number is too low because the accused defendants accepting legal sanctions only are the tip of the iceberg of the number of all criminals. It needs enhancement and encouragement for people and NHI to report the criminal information to our judicial units, in order to deter the doctors from committing the crime of health care. The study found that present criminal law has no effect on deterrence from committing health care fraud, because the average sentence for health care fraud is about 8-9 months, and probation rate is higher than other fraud case. Therefore, this study shows that the current problems for health care fraud sentencing are legal aspects for judgment: (1) the degree of punishment is too low (2) capital felony but lenient sentence (3) no standard sentencing guideline. Therefore, to prevent the occurrence of health care fraud, amending the law in the future is necessary. The authors propose the following suggestions: First, add special articles or special section for health care fraud in the criminal law. Second, increase sentencing penalties and fines. Third, set up specialized tribunal to investigate and put to trial for health care fraud, and to improve the quality of the adjudgement. Fourth, we should learn to set up team model to fight against health care fraud from U.S. experience. For example, to establish integrated prevention units for health care fraud from various branches of National Health Insurance Bureau, the prosecutors office of Ministry of Justic, the Department of Health and local health authorities. Fifth, to review the regulations and articles of NHI related to inspection and punishment for the medical fraud immediately. Strict inspection and punishment for committing health care fraud is necessary, especially for physicians and medical institutions with poor management. Implement permanent health insurance contract termination for administrative sanctions is necessary to prevent the occurrence of health care fraud. Finally, enhancing the administrative penalties against physicians committing health care fraud crime from health authorities and the Department of Health, such as warnings, limit the scope of practice, suspension, revocation of license to practice is also regarded as an effective modality to prevent health care fraud
Type
journal article