[의학신문·일간보사=이승덕 기자]Public insurance and private insurance work jointly to catch insurance scams such as the secretary’s hospital.
The National Health Insurance Corporation (Chairman Yong-ik Kim) announced that it will launch the’Public and Private Insurance Joint Investigation Council’ in collaboration with the Financial Supervisory Service, Life Insurance Association, and Non-life Insurance Association.
In order to prevent financial leakage of national health insurance due to insurance fraud, the Public-Private Insurance Joint Investigation Council conducts intensive investigations on false or unfair claims for national health insurance and on insurance fraud for real loss insurance by private insurance companies.
Insurance fraud greatly affects the fiscal soundness of public insurance (national health insurance) as well as private insurance, and thus acts as a burden on the national economy as a whole.
However, due to the limitation of information sharing between public and private sectors, there was a problem that private insurance fraud and health insurance false or unfair claims investigation could not be linked.
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For example, in the case where the secretary’s hospital deprives private insurance and health care benefits at the same time due to’false hospitalization’, the investigation was not conducted well because there was no linkage in the meantime.
After establishing a medical corporation by fraudulent method, Mr. A incurred 5 billion won in medical care benefit expenses to the National Health Insurance Corporation by falsely writing medical records, etc., as if 191 patients were not actually hospitalized, as if they were hospitalized and received normal treatment. Unfair claims were made, and patients (191 patients) unfairly claimed and received 1.8 billion won in insurance from insurance companies (31).
In the case of Mr. B, by lending only the names to five doctors, two hospitals were opened to attract false inpatients, and long-term hospitalization for more than two weeks is difficult in a clinic-level hospital, so medical records are manipulated as if moving hospitals in two weeks. By means of such methods, the hospital deducted 1.94 billion won from the National Health Insurance (1.9 billion won), and patients (61 patients) unfairly claimed and received 3 billion won in insurance from the insurance company.
Accordingly, the Corporation decided to hold a joint public-private insurance joint investigation council on a regular basis and conduct joint investigations (operating a TF) on large-scale insurance fraud cases linked to health insurance and private insurance.
It is expected that this public-private cooperation will increase the efficiency and detection effect of insurance fraud investigations.
Kang Cheong-hee, senior salary director of the Health Insurance Corporation, said, “Through this council, we will strengthen investigations into private insurance fraud, secretary hospitals, and false or unfair claims for health insurance through close collaboration with related organizations, to achieve sound health insurance finances, and to reduce the economic burden of the people. He emphasized that the Corporation will take the lead in the efforts to curb the increase in the actual loss insurance premiums.
In addition, “The blind spot of public and private insurance fraud that has not been investigated has been resolved due to the joint investigation with the Financial Supervisory Service and Insurance Association, and after discovering a planning theme for a joint insurance fraud investigation, after analyzing the suspicion point, a joint investigation was submitted to the investigating agency to be alert. It is expected to greatly contribute to the prevention of insurance fraud through improvement.”