【正文】 （四）檢查、治療、用藥等與病情不符的； 治療單、報(bào)告單、實(shí)際用藥情況與醫(yī)囑不相符的； 病歷記載不清、病歷未記載卻有收費(fèi)、重復(fù)收費(fèi)、分解收費(fèi)的； 疾病診斷、治療轉(zhuǎn)歸等方面弄虛作假的； 社會(huì)保險(xiǎn)監(jiān)督管理 （五）電腦錄入的參保人基本信息、收費(fèi)項(xiàng)目等與醫(yī)療記錄不相符的，或因乙方電腦系統(tǒng)不完善、操作不規(guī)范等引起的錄入數(shù)據(jù)與實(shí)際費(fèi)用不相符的； 社會(huì)保險(xiǎn)監(jiān)督管理 （六）違反物價(jià)政策及定點(diǎn)醫(yī)療機(jī)構(gòu)所在地物價(jià)標(biāo)準(zhǔn)，以及不按物價(jià)部門規(guī)定的非營利性醫(yī)療機(jī)構(gòu)收費(fèi)標(biāo)準(zhǔn)收費(fèi)的； （七）不具執(zhí)業(yè)醫(yī)師資格的人員、被暫?；蛉∠鐣?huì)保險(xiǎn)處方權(quán)的醫(yī)生開具社保處方的。 社會(huì)保險(xiǎn)監(jiān)督管理 第七十八條 下列行為屬重大違規(guī)，乙方有下列違規(guī)行為之一，視情節(jié)輕重應(yīng)向甲方支付違規(guī)費(fèi)用數(shù)額 35倍的違約金： （一）虛開、買賣、轉(zhuǎn)讓門診和住院票據(jù)的； 社會(huì)保險(xiǎn)監(jiān)督管理 （二）利用電腦系統(tǒng)盜取社保統(tǒng)籌基金或利用社保信息系統(tǒng)等手段將醫(yī)療費(fèi)用記入他人名下的； 處方書寫、診療單據(jù)項(xiàng)目填寫與電腦錄入不相符或藥品進(jìn)出貨有出入，經(jīng)核實(shí)有違反醫(yī)療保險(xiǎn)規(guī)定行為（換購藥品、換購物品或套取現(xiàn)金等）的； 社會(huì)保險(xiǎn)監(jiān)督管理 （三）病歷造假，即在病歷上編造參保人的基本情況和診療情況，使病歷內(nèi)容與真實(shí)情況不相符的； （四）銷售假、劣藥品或過期藥品的； 社會(huì)保險(xiǎn)監(jiān)督管理 （五）擅自為未取得定點(diǎn)醫(yī)療資格的下設(shè)或其他醫(yī)療機(jī)構(gòu)開通醫(yī)保記賬的； （六）采取其他違規(guī)手段增加社會(huì)保險(xiǎn)基金不合理支出的。 社會(huì)保險(xiǎn)監(jiān)督管理 第七十九條 甲方對(duì)乙方進(jìn)行常規(guī)抽查發(fā)現(xiàn)乙方出現(xiàn)違規(guī)行為的，按照第七十六條、第七十七條、第七十八條規(guī)定進(jìn)行違規(guī)處理；甲方對(duì)乙方進(jìn)行全面檢查發(fā)現(xiàn)乙方出現(xiàn)違規(guī)行為的，按 13倍扣除違約金。 社會(huì)保險(xiǎn)監(jiān)督管理 第八十條 在一個(gè)社會(huì)保險(xiǎn)年度內(nèi)，發(fā)生的非本人社會(huì)保障卡記賬的，同一醫(yī)生被有效投訴的門診處方次數(shù)超過 3例及以上、住院 1例及以上或被新聞媒體直接報(bào)導(dǎo)影響較大經(jīng)查屬實(shí)的，甲方可對(duì)該醫(yī)生作出如下處理： 要求其書面檢查、警告、通報(bào)批評(píng)、暫?；蛉∠渖鐣?huì)保險(xiǎn)處方權(quán)等。 社會(huì)保險(xiǎn)監(jiān)督管理 甲方應(yīng)建立對(duì)乙方核驗(yàn)社?？ㄍ▓?bào)表揚(yáng)制度，在一個(gè)醫(yī)療保險(xiǎn)年度內(nèi)，乙方將保存好的冒卡就醫(yī)原始材料提交甲方，甲方對(duì)典型事例進(jìn)行通報(bào)表彰。 社會(huì)保險(xiǎn)監(jiān)督管理 第八十一條 乙方被暫時(shí)中止或終止社會(huì)保險(xiǎn)協(xié)議的，分別扣除年度與社會(huì)醫(yī)療保險(xiǎn)服務(wù)質(zhì)量掛鉤 5%醫(yī)療費(fèi)用的 50%或100%。 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