The Ministry of Health and Welfare announced that it will publish a list of 58 medical institutions and other entities that submitted false claims for health insurance medical benefits for a period of six months starting October 1. The total amount falsely claimed by these institutions is 4.66993 billion won.
The entities subject to public disclosure include 2 hospitals, 36 clinics, 10 dental clinics, 8 Korean medicine clinics, and 2 pharmacies. The list includes 56 institutions selected following deliberation by the National Health Insurance Public Disclosure Deliberation Committee from among those that received suspensions of operations or administrative fines for fraudulent claims between September of last year and the end of February this year, as well as two institutions added based on the outcomes of administrative litigation regarding the disclosure sanctions.
The average amount of fraudulent claims per facility was 80.51 million won, and the average duration of the fraudulent claims was 31 months. By amount, 22 facilities had fraudulent claims totaling 15 million won or more but less than 30 million won; 12 institutions had amounts between 30 million and 50 million won, 13 institutions had amounts between 50 million and 100 million won, and 11 institutions had amounts exceeding 100 million won. The largest amount was 927.37 million won. In terms of the ratio of fraudulent claims to total medical benefit costs, the most common category—38 facilities—had a ratio of 1% or more but less than 10%, and there were also 3 facilities with a ratio of 30% or more. The highest ratio was 55.34%.
According to cases disclosed by the Ministry of Health and Welfare, Medical Institution B falsely claimed 927.37 million won over a 17-month period for consultation fees, traditional Korean medicine procedures, and treatment costs by fabricating records to make it appear as though patients had visited and received treatment, even though they had not actually done so. In addition to being required to return the unjust enrichment, this facility was fined 4.63689 billion won, had its name publicly disclosed, and was charged with fraud. Medical Institution A falsely claimed to have performed a greater number of radiological imaging procedures than actually occurred, billing 45.38 million won over a 36-month period; as a result, it was fined 90.75 million won, had its name publicly disclosed, and was referred to prosecutors.
Pursuant to Article 100 of the National Health Insurance Act, institutions subject to public disclosure are those that have received administrative sanctions for false claims where the amount of the false claims is 15 million won or more, or where the ratio of false claims to the total medical benefit costs is 20% or higher. A Public Disclosure Review Committee, consisting of 11 members—including representatives from consumer groups, journalists, legal experts, the medical and pharmaceutical sectors, the National Health Insurance Service, the Health Insurance Review and Assessment Service, and the Ministry of Health and Welfare—makes the decision after considering the motive, severity, frequency, and consequences of the violation. The institutions subject to disclosure were given a 20-day period to present their case following prior notification, and the final decision was confirmed after a re-review.
The disclosed information includes the institution’s name, address, type of facility, representative’s name and license number, details of the violation, and the administrative sanctions imposed. The list will be posted on the websites of the Ministry of Health and Welfare, the Health Insurance Review and Assessment Service, the National Health Insurance Service, the relevant metropolitan cities, provinces, cities, counties, and districts, and public health centers until March 31, 2027. On the Ministry of Health and Welfare’s website, it can be found under the “Notices—Public List” menu.
The list is published twice a year, in the first and second halves of the year. Since the system was implemented in February 2010 through April of this year, a total of 613 institutions have been listed, with 311 general medical clinics, 187 Korean medicine clinics, and 53 dental clinics in that order.
Yoo Ju-heon, Director General of the Health Insurance Policy Bureau at the Ministry of Health and Welfare, stated, “We will continue to conduct on-site investigations of institutions suspected of submitting fraudulent health insurance claims and, in addition to administrative sanctions, strictly enforce the publication of the list for medical institutions found to have submitted fraudulent claims. Through these measures, we will raise awareness about the dangers of fraudulent claims and strive to prevent the waste of health insurance funds.”
