국민건강보험 요양급여 사후관리 체계 현황과 개선방향
Current Status and Future Directions of the Post-Management System for Reimbursed Services in the National Health Insurance
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To prevent and detect inappropriate payments for health insurance claims, the government imple- ment policies at all levels of the national health insurance system, which occur despite reviews con- ducted by Health Insurance Review and Assessment Service and payments made by the National Health Insurance Service. The Ministry of Health and Welfare can investigate a health care provider for suspected fraudulent claims and impose administrative measures and penalties such as mone- tary fines and suspension in case there is proof of indiscretion. Payers also identify potentially false claims by reviewing whether more services than necessary were provided. However, the system has also been criticized for being restriction oriented and not performing ordinary functions because of the occurrence of numerous untreated cases. We identified current state by reviewing policies and laws that attempted to combat healthcare fraud and abuse in national health insurance system and suggested new directions.
Abstract
To prevent and detect inappropriate payments for health insurance claims, the government imple- ment policies at all levels of the national health insurance system, which occur despite reviews con- ducted by Health Insurance Review and Assessment Service and payments made by the National Health Insurance Service. The Ministry of Health and Welfare can investigate a health care provider for suspected fraudulent claims and impose administrative measures and penalties such as mone- tary fines and suspension in case there is proof of indiscretion. Payers also identify potentially false claims by reviewing whether more services than necessary were provided. However, the system has also been criticized for being restriction oriented and not performing ordinary functions because of the occurrence of numerous untreated cases. We identified current state by reviewing policies and laws that attempted to combat healthcare fraud and abuse in national health insurance system and suggested new directions.
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