More than 100 reports of illegal or improper acts were filed in about 50 days after the Ministry of Health and Welfare launched its tip center to root out abnormal and fake medical services. The types varied widely, from so-called "payback," in which patients are refunded part of their medical bills, to false or improper claims, patient inducement or brokering, and suspected "manager-run hospitals."
The ministry said on the 11th that, as of Aug. 7, a total of 102 tips had been filed with the tip center, which began operating in June alongside the launch of the "abnormal and fake medical services administrative investigation team."
By type, false or improper claims for medical fees were the most common at 27 cases, followed by illegal refunds of medical fees (payback) and patient inducement or brokering at 26 cases each. There were nine tips related to packages that bundle noncovered treatments, and three suspected cases of manager-run hospitals.
By type of medical institution, clinics had the most at 26 cases, followed by Korean medicine hospitals with 23 and long-term care hospitals with 21. By region, Seoul had the most at 33, followed by Gyeonggi and Incheon with 29, South Jeolla and Gwangju with 15, and Busan and South Gyeongsang with 10.
Among the actual tips was a case in which a hospital allegedly falsified medical records to make it appear a patient had been admitted when they had not, and had the patient claim indemnity insurance benefits. The hospital is suspected of refunding part of the legally required copayment to the patient and even providing a separate mobile phone to the patient to avoid base station location tracking. The ministry said such conduct could constitute falsifying medical records and insurance fraud.
There were also suspected cases of so-called "manager-run hospitals," in which an investor who is not a medical professional effectively runs a hospital. According to one report, a physician who is the hospital's representative received funds from an investor to establish the hospital, after which the investor took charge of overall management and received a fixed amount each month in return.
There were cases in which noncovered treatments were presented as a condition for admission. At one hospital, during the admission consultation, staff checked whether the patient had indemnity insurance, then required bundled noncovered treatments such as immune injections and chemotherapy side-effect management, and induced the patient to pay high medical bills in a short period, according to a tip.
Cases that induce patients to introduce other patients are also subject to enforcement. One hospital reportedly awarded points to existing patients who recruited patients through internet cafes and social media (SNS) and instructed that those points could be used for premium meals or spa and other convenience services within the hospital, as well as pickup and drop-off services. The ministry believes this could constitute introducing, brokering, or inducing patients for profit.
The ministry will conduct preliminary analysis of the tips using big data from the National Health Insurance Service and the Health Insurance Review & Assessment Service, then carry out on-site administrative investigations and refer cases for criminal investigation if illegality is confirmed. The administrative investigation team has so far referred 18 medical institutions for investigation and is considering additional referrals for multiple institutions, including those where administrative investigations were conducted in July.
Tipsters' identities are strictly protected. Anyone can report, including medical institution workers, patients, and guardians. The more specific the submission—such as the medical institution's name and relationship to the tipster, the time and place of the illegal act, consultation or call records, photos, medical bill details, and proof of monetary transactions—the more it helps with investigation and prosecution.
Gwak Sun-heon, head of the abnormal and fake medical services administrative investigation team, said, "Abnormal and fake medical services undermine the medical order and seriously violate the law by harming not only people's lives and health but also trust in the national health insurance and private insurance systems," adding, "If illegal acts are confirmed, we will take strict action according to the law and principles."
Gwak added, "As the number of tips increases, the types of abnormal and fake medical services and the number of suspected institutions are growing," and said, "We will actively consider deploying additional administrative resources to root out illegal and improper acts."