Doctors are seen at Kyungpook National University Hospital in Daegu on Sept. 4, 2020.NEWS1
A clinic billed the national health insurance system for treating a patient's back on Oct. 5 and 6, 2024. But an on-site inspection by health authorities showed that the patient was overseas at the time, having left the country on Oct. 4 and returned on Oct. 7.
The case is one of 7.8 million improper health insurance claims filed by local clinics over the past five years, which amounted to a total of 140.8 billion won ($104.9 million) from 2021 to September this year, according to the data from the Health Insurance Review & Assessment Service submitted to Rep. Baek Sun-hee of the Rebuilding Korea Party on Tuesday.
On-site inspections are post-payment reviews of health insurance benefits already paid to medical institutions. The Ministry of Health and Welfare, together with the Health Insurance Review & Assessment Service and other agencies, checks whether the payments were improperly claimed.
Authorities select medical providers that are considered more likely to have made improper claims and inspect about 1 percent of all providers.
The inspections cover cases in which medical institutions claim to have treated patients who received no care or issue bills for tests, procedures or medications that were never provided. Institutions found to have made improper claims can face business suspension or fines.
Improper claims worth 25.35 billion won were uncovered at 497 institutions last year. Dentists' offices accounted for the largest amount at 6.06 billion won, followed by local clinics at 5.48 billion won and hospitals at 4.5 billion won.
Signs for plastic surgery clinics stand in a street in Seoul on Jan. 28, 2024.YONHAP
Improper claims worth 20.22 billion won were uncovered at 272 institutions through September this year, already about 80 percent of last year’s full-year total, the data showed.
False filings were found at 89.4 percent of the institutions inspected last year and 86.1 percent of those inspected this year.
The increase has been particularly stark at traditional Korean medicine hospitals.
Improper claims detected at traditional Korean medicine hospitals jumped from 164 million won in 2021 to 3.2 billion won through September this year — an increase of nearly 20-fold. The amount uncovered in the first nine months of this year alone has already exceeded last year’s total of 2.6 billion won.
All 18 of the Korean medicine hospitals inspected this year were found to have made improper claims.
However, because the on-site inspections do not cover every medical institution, it is difficult to determine the true scale.
Pedestrians pass Jaseng Hospital of Korean Medicine in Gangnam District, southern Seoul, on July 9.YONHAP
Critics argue that a more sophisticated review and monitoring system is needed to make up for the limited scope of inspections and prevent further losses from the national health insurance fund.
“The fact that tens of billions of won in improper claims are uncovered every year is less a sign of successful enforcement by the Health Insurance Review and Assessment Service than evidence that health insurance funds are leaking because those claims were not caught in advance,” Rep. Baek said. “Oversight and supervision must be strengthened to stop improper claims before they are paid so that premiums contributed by the public are not wasted.”
This article was originally written in Korean and translated by a bilingual reporter with the help of generative AI tools. It was then edited by a native English-speaking editor. All AI-assisted translations are reviewed and refined by our newsroom.
