台灣健保詐欺量刑標準之實證研究

The evidence-based research for the sentencing guidelines for general health insurance fraud

系所名稱：管理學院科技法律學程 學位別：碩士 畢業學年：102年 指導教授：林志潔、陳鋕雄 研究之目的: 保險詐欺是一種低風險低成本與高利潤之犯罪，而健保詐欺事涉醫療專業，審查與舉證更加困難，常常與健保浪費無法區分。而醫師又是社會大眾所敬重之高階知識分子，具有一般民眾所欠缺之醫學專業知識，而利用其專業醫療知識來進行之健保詐欺行為，以獲取不當之利益，更是屬於白領犯罪的一種類型。全民健康保險自民國 84 年開辦至今已逾 16年，屬於強制性的社會保險，其主要宗旨在使全民納保、普遍繳費、就醫無礙。以往詐領保險公司給付之保險詐欺行為，近年來逐漸蔓延蠶食健保給付領域，且不肖醫師詐領健保的方法也跟著日新月異。在民國89至96年的研究發現，我國司法判決實難對於醫療詐欺產生有效的嚇阻作用，因為平均刑期約10個月，且緩刑機會比一般詐欺案件高。每年之件數沒有統計上之差異。並且再犯占86.6%，而非再犯只占13.4%。簡言之，我國司法在審理健保詐欺案件時，的確對具醫師身份的被告較為寬容。 本研究之目的擬藉由分析民國九十七年至一百年地方法院對於醫療詐欺之判決，並與之前的相關研究與判決結果作比較與分析，以探討各種處分方式（起訴、緩起訴或不起訴等）是否相當或具有防止醫療詐欺之嚇阻效果，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。 研究方法: 本文所採取的研究方法主要為內容分析法，研究內容之資料來源為司法院裁判書查詢系統。統計期間：97年1月1日至100年12月31日。審理機關為全國21個地方法院（第一審刑事判決）。篩選條件為詐領全民健康保險給付相關案件。搜尋關鍵字為詐領健保、溢領健保、虛報健保、浮報健保、向健保局詐領、詐領醫療費用。本研究方法以敘述性統計（Descriptive）之平均數（Mean）及標準差（Standard Deviation） 描述各個變項現況。本研究統計民國97年到 100 年全國地方法院健保詐欺判決案例有97件（184名被告），扣除20件未記載詐欺金額者，共有77件判決案例列入本次分析。統計軟體為SPSS (Statistical Package for the Social Science) ，統計方法有平均數 （Mean）及標準差（Standard Deviation），皮爾森相關係數（Pearson correlation coefficient），卡方檢定（Chi-square test），費雪精確性檢定（Fisher's Exact Test），單因子變異數分析（One-way ANOVA），多元迴歸分析（Multiple regression analysis），虛擬變項（Dummy Variable）等來作統計分析與校正，以求量化研究結果之正確性。 研究結果: 研究結果發現，每件判決案例之「詐欺金額」，平均為1,177,075元。「判刑天數」平均為259天；「緩刑天數」平均為593天。「罰鍰金額」平均為284,935元。將詐欺金額以100,000為界線作分組時，「詐欺金額小於100,000元」者較多，計50件（64.9%）。在判刑天數方面，以365天（一年）為界分組時，「判刑天數小於365天」者較多，計60件（77.9%）。詐欺金額與判刑天數達顯著正相關，代表詐欺金額愈高，判刑天數也會愈高；而詐欺金額與緩刑天數、罰鍰金額則無相關存在。判刑天數與罰鍰金額達顯著正相關，代表判刑天數愈高，罰鍰金額也會愈高；而判刑天數與緩刑天數則無相關存在。最後，緩刑天數與罰鍰金額達顯著正相關，代表緩刑天數愈高，罰鍰金額也會愈高。綜合而言，而在調整年度的影響下，詐欺金額對判刑天數的影響是正向的，即案例的詐欺金額每增加一百萬，則預期其判決天數增加33.92天。由民國97~100年之健保詐欺案件分析得知，以醫師犯與再犯的案件最多，其次為非醫師與再犯的案件。可見以目前之量刑判決，對於遏止健保詐欺的再發生，完全沒有效果。同時由醫療詐欺案件的種類分析得知，以健保申報不實，詐領健保給付的案件最多。因此健保詐欺是最容易與最常見的醫療詐欺犯罪態樣，值得司法單位與衛生福利部與健保署的重視。 實證結果評析與結論: 本研究結果顯示緩刑判決無客觀標準，判決與罰金也無客觀標準，判決天數與詐領金額雖有相關性，但是法官個人的自由心證變異性太大，也沒有量刑的客觀標準。然而統計民國97年到100年全國地方法院健保詐欺判決案例只有97件（184名被告），實屬偏低，被告發接受法律制裁的數量只是冰山之一角，有待未來強化與獎勵民眾與健保局提出檢舉與告發，讓犯罪醫師不敢以身試法。本研究發現我國刑法無法對醫療詐欺犯罪產生有效的嚇阻作用，因為平均刑期約8-9個月，且緩刑機會比一般詐欺案件高。因此，本研究顯示，目前本國健保詐欺量刑所面臨的問題是在法制面上:(1)、刑度過低 (2)、重罪輕判(3)、審判標準不一。 因此，要預防健保詐欺犯罪之發生，對於未來修法的方向，作者提出下列幾點建議:第一要增列專條或專節規定。 第二要加重罰金罰則。第三要設立專庭偵查及審判案件，並提升裁判品質。第四要學習美國對於打擊醫療詐欺犯罪的團隊合作模式。 例如，在健保局各分局、法務部各地檢署、衛生署、及各縣市衛生局能夠針對醫療詐欺犯罪成立整合性的防治單位。第五要立即檢討有關全民健保稽查與處罰之法規。對於詐領健保之犯罪醫師與醫療機構，特別是經營不善之診所與中小型醫院，要嚴加稽查，若有不法，則必須實施永久解除健保合約之行政處分，才能徹底防堵健保詐欺犯罪之發生。最後，提高行政法上對個人的處罰，例如衛生局與衛生福利部對於醫護人員的懲戒罰，比如警告、限制執業範圍、停業、廢止執業執照或廢止資格證書之懲戒處分等，也是不失為防止健保詐欺犯罪的方法。

Objectives: Insurance fraud is a crime of low-cost, low-risk and high-profit, and health care fraud involves medical professionals, leading to difficulty in preview and proof, and often is indistinguishable from health care wasting. The physicians are highly respected by our community, they have medical expertise that is lacking in general population. The use of medical expertise to perform health care fraud and to obtain improper benefits, this crime is a type of white-collar crime. The National Health Insurance (NHI) went into effect on March 1, 1995. It is a mandatory social insurance, its main purpose is general insurance coverage, universal payment, and without medical obstacle. Insurance fraud in the past occurred in the private insurance, but in recent years, it gradually spreads to NHI. The methods used by unscrupulous physicians in health care fraud are also changing in recent years. In the research during 2000-2007 showed that the judicial judgments are difficult to produce effective deterrence, because the average prison term is about 10 months, and probation rate for health care fraud is higher than the general fraud case. No statistically significant difference in the annual number for health care fraud was observed during these 8 years. And the rate of recidivism accounted for 86.6%. In short, our judicial judgment for health care fraud showed more tolerant to the defendant physicians. The purpose of this study is intended to analyze the first reviews of judgment for health care fraud in the District Court between 2008 and 2011, and compare to that in previous studies, in order to explore the ways of punishment (prosecution or deferred prosecution or not.) are suitable or not, and have the effects to deter health care fraud or not. Finally, the research also explore the sentencing standards from district court judgment are reasonable and objective or not, to make recommendations to amend the law and propose control measures to prevent health care fraud, and avoid the improper wasting or fraud of NHI to ensure the sustainable management of NHI. Methods: The research method adopted in this study mainly is content analysis. The study uses quantitative research method, searching for judgments meeting the definition of health care fraud between 2008 and 2011 from the first reviews of 21 district courts of the Judicial Yuan. Screening criteria are cases related to health care fraud for NHI. Search keywords are fraud for NHI, overflow for NHI, false declaration for medical expenses to NHI. The statistical methods are descriptive statistics, using the average (Mean) and standard deviation to describe the status of each variable. In this study, total 77 judgments (total 184 defendants) form district courts between 2008 and 2011 are included in statistical analysis. Statistical software is SPSS (Statistical Package for the Social Science), statistical methods include mean and standard deviation, Pearson correlation coefficient, Chi-square test, Fisher's Exact Test, one -way ANOVA, multiple regression analysis and dummy variables to perform statistical analysis and correction, in order to ensure the correctness of the results from quantitative research. Results: this study result showed that each judgment on average fraudulently collected NT＄1,177,075. Each case was convicted at the first review by district courts with the average prison term of 259 days, and with the average probation term of 593 days. The average amount of fines was NT＄ 284,935 in each judgment. When we use the sum of fraud of 100,000 as the cut-off value, the cases of fraud sum less than NT＄ 100,000 were more than the cases of fraud sum more than NT＄ 100,000, with total 50 cases (64.9%). In terms of the number of sentenced days of 365 days (one year) for grouping, the number of cases with sentenced days less than 365 days were more than that with sentenced days more than 365 days, with total 60 cases (77.9%). The sum of fraud and sentenced days have a significant positive correlation, it means that when the sum of fraud is higher, the sentenced days will be longer. While the number of probation days and the sum of fines have no correlation with the sum of fraud. The sentenced days and the sum of fines have a significantly positive correlation, it means that when the number of sentenced days is longer, the sum of fines will be higher. While the number of probation days and the sentenced days have no correlations. Finally, the numbers of probation days and sum of fines have a significant positive correlation, it means that the longer of the probation days, the higher of the sum of fines. Overall, under the impact of the adjusted year, the impact of the sum of fraud on sentenced days is positive, that is, when the sum of fraud increased one million, the expected sentenced days will increase 33.92 days. The analysis of health care fraud between 2008 and 2011 demonstrates that most cases are physician defendants and case of recidivism, followed by non-physicians and recidivism cases. The conclusions elucidate that current sentencing judgment has no effect on deterrence for health care fraud. The analysis for the types of health care fraud showed that most cases are untrue registration and claim for payment without providing medical service or claim for payment higher than that required for the medical service provided. Therefore, health care fraud is the easiest and most common medical fraud crime, it is worthy of the attention of justice, the Ministry of Health and Welfare and the National Health Insurance Department.Comments and conclusions for this empirical study: 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 prosecutor's 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.