Crackdown on "Fake Treatments and Fake Patients"... National Health Insurance Special Investigation Resumes Next Month

Ministry to Inspect Practices Such as Inflating Inpatient Days
Up to One-Year Suspension or Fines Up to Five Times the Amount if Detected
Rewards for Reporting Fraud Up to 3 Billion Won

The government will resume a large-scale special investigation targeting fraudulent claims such as "fake treatments and fake patients" in order to prevent health insurance fund leakage.

The Ministry of Health and Welfare announced on July 13 that it will conduct the "2026 National Health Insurance Special Investigation" from August to October, targeting medical institutions that frequently submit false claims under the National Health Insurance system.

A special 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. For the past two years (2024-2025), these investigations were suspended due to the impact of COVID-19 and other factors.

Fraudulent claims are a representative type of health insurance misconduct, where institutions charge for treatments that were not actually performed. The scale of health insurance fund leakage caused by such fraudulent claims has been estimated at an average of 9.6 billion won per year. This investigation will focus on medical institutions and hospitals where the likelihood and amount of fraudulent claims are especially high, including so-called "doctor-for-hire" hospitals suspected of illegal practices.

The institutions to be investigated were selected based on the analysis results from the Health Insurance Review and Assessment Service's "Improper Claims Detection System." The investigation items were finalized through deliberation by the Local Investigation Selection Committee, which includes legal professionals, medical experts, and civic groups. The Ministry of Health and Welfare will focus on five main types of misconduct: ▲ inflating the number of hospitalization or outpatient visits ▲ double-claiming by making patients pay the full cost of non-insured services and then claiming the same amount from health insurance ▲ charging for treatments or medications that were not actually performed or administered ▲ inflating the number of medical procedures ▲ claiming costs for treatments or prescriptions performed by unqualified individuals.

If fraudulent claims are detected, not only will the illicit gains be reclaimed, but the institution may also face up to one year of suspension from work or a fine up to five times the improper amount, in accordance with the National Health Insurance Act. In addition, administrative measures such as public disclosure of the institution's name and suspension of medical licenses will also be imposed.

The Ministry of Health and Welfare plans to pre-announce the investigation items through relevant medical associations and on the websites of the Ministry, the Health Insurance Review and Assessment Service, and the National Health Insurance Service to increase predictability and acceptance. Furthermore, the government will establish a real-time monitoring system using artificial intelligence (AI) and big data-based improper claims detection systems. Whistleblowers who report fake treatments or fake patients will be rewarded with up to 3 billion won, depending on the scale of detection and recovery.

Kwon Byunggi, Director of the Health Insurance Policy Bureau at the Ministry of Health and Welfare, stated, "By resuming the special investigation, which had been suspended for the past two years, and focusing on detecting fake treatments and fake patients, we will protect the health insurance fund, which is operated using the precious insurance premiums paid by the public."

This content was produced with the assistance of AI translation services.