The ‘National Health Insurance planned investigations’ that had been suspended for the past two years for reasons including COVID-19 will resume in the second half of this year. The first targets are the so-called ‘fake treatment·fake patients’, who cause leakage from National Health Insurance finances by making it appear as though treatment was provided when it was not.

The Ministry of Health and Welfare announced on the 4th that it plans to begin in earnest as early as August a planned investigation focused on uncovering health insurance ‘false claims’. A planned investigation is an on-site inspection conducted in areas that require improvement in the operation of the health insurance system or where social issues have been raised. In 2024 and 2025, planned investigations were suspended due to COVID-19 and other reasons.

False claims refer to the act of billing as if medical services were provided when they were not. Major cases uncovered include inflating the number of hospitalization days or outpatient visits, double-billing after non-covered services, billing for benefits, medical supplies, or drug costs that were not provided or administered, inflating the number of medical procedures, and claiming costs arising from treatment or dispensing by unqualified persons. According to the Ministry of Health and Welfare, the annual average leakage from National Health Insurance finances detected due to such false claims is about KRW 9.6 billion, accounting for around 30% of the total amount of improper claims.

Institutions uncovered through planned investigations are subject to strict sanctions. The confirmed false-claim amount is fully recovered as unjust gains, and business suspension of up to one year is imposed. If suspending operations would cause severe inconvenience to users of the health care institution, a surcharge of up to five times the total improper amount may be imposed instead. For example, if the improper amount is KRW 2 billion, a maximum surcharge of KRW 10 billion plus the recovery of KRW 2 billion would be levied, for a total of KRW 12 billion.

Criminal referral under the relevant laws will also proceed. In particular, health care institutions with a false-claim amount of at least KRW 15 million or a false-claim ratio of 20% or higher will have their violations disclosed to the public following a resolution by the Health Insurance Disclosure Deliberation Committee. In addition, if violations of the Medical Service Act are uncovered together, such as falsifying medical records, the physician involved may be subject to license suspension for up to one year.

To enhance fairness and objectivity in the investigation, the ministry will finalize specific items and timing and announce them in advance this month after deliberation by the ‘On-site Investigation Selection Deliberation Committee’, which includes private-sector experts from the medical and pharmaceutical community. The committee will have 11 members in total: 3 public members, 5 from medical and pharmaceutical organizations, 1 from a civic group, and 2 experts.

The improper-claim detection system of the Health Insurance Review and Assessment Service will be used to select investigation targets. Through this system, the ministry will focus analysis on types with a high likelihood of false claims and high potential detected amounts to enhance the effectiveness of the investigations.

The Ministry of Health and Welfare stated, “Through planned investigations into false claims such as fake treatment and fake patients, we will prevent leakage from National Health Insurance, which is operated with the precious premiums of the public,” adding, “We plan to establish a normal claims culture with no false or improper claims through swift and effective follow-up management.”