Targeted inspections to begin as early as August; items to be confirmed and announced in advance through review committee

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The Ministry of Health and Welfare said Thursday it will conduct a targeted national health insurance investigation in the second half of this year to crack down on hospitals and clinics that submit fraudulent or improper claims for medical reimbursements.

The targeted investigation is an on-site probe carried out in areas where systemic improvements are needed or where social concerns have been raised about the national health insurance regime.

The government conducts routine monthly inspections under the National Health Insurance Act, but this initiative raises the intensity of scrutiny to focus specifically on fraudulent billing — including phantom treatments and fictitious patients — reviving a targeted investigation format suspended for the past two years.

Fraudulent billing includes charging for treatments that were never performed or billing for services as though a physician was present when that doctor was not actually on duty.

Fraudulent claims drain an average of about 9.6 billion won ($6.33 million) from national health insurance finances each year, accounting for roughly 30 percent of all improper billing.

Following a preparation period, the second-half targeted investigation is set to begin in earnest as early as August.

To strengthen the fairness, objectivity and credibility of the probe, the ministry plans this month to convene the On-site Investigation Selection and Review Committee — a panel that includes private-sector experts from the medical and pharmaceutical fields — to deliberate on and finalize the investigation items and schedule. Those details will then be announced in advance.

Investigation items will be selected through a focused analysis of claim types with a high likelihood of fraud and large detected amounts, using the Health Insurance Review and Assessment Service's improper-billing detection system.

Fraudulent claims confirmed through the targeted investigation will be subject to swift and effective follow-up enforcement under applicable laws and regulations, the ministry said.

Amounts identified as fraudulent will be recovered as unjust enrichment. On top of that, providers face a suspension of operations of up to one year. Where a suspension is not practicable, a penalty surcharge of up to five times the improper billing amount may be imposed.

Institutions confirmed to have submitted fraudulent claims will also be referred for criminal prosecution, in addition to any operational suspension or financial penalty.

Medical institutions where fraudulent billing amounts reach 15 million won or more, or where the fraudulent billing rate is 20 percent or more, will have their violations disclosed to the public following a resolution by the National Health Insurance Disclosure Review Committee.

If violations of the Medical Service Act are found — such as falsifying medical records — healthcare professionals may face a license suspension of up to one year.

Kwon Byeong-gi, director general of the Health Insurance Policy Bureau at the Ministry of Health and Welfare, said the investigation would ensure that "no funds are lost from the national health insurance system, which is sustained by the precious premiums paid by the public." He added that the ministry would work to "establish a culture of legitimate billing, free from fraudulent and improper claims, through swift and effective follow-up management."


thlee@heraldcorp.com