• Journal of the Korean hospital association
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• v.37 no.5
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• pp.100-104
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• 2008

• Journal of dental hygiene science
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• v.15 no.6
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• pp.815-824
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• 2015

This study aims to figure out the current state of health insurance education provided to dentists and personnel in charge of insurance claim as well as the effects of experiences in education on their knowledge of health insurance standard and actual application. As a result of analysis on 100 data sheets related to dentistry and 100 data sheets related to personnel in charge of insurance claim (a total of 200 data sheets), following results were generated. Insurance claim personnels showed higher score than dentist in knowledge of health insurance standard and it was significant statistically. Knowledge of insurance claim personnel showed significant differences in educational experiences, in health insurance for the latest three years and average hours of education per session whereas that of dentists did not indicate any significant differences. The level of practical application of dentists was significantly different (p<0.05) according to experiences in insurance claim, and that of insurance claim personnel significantly varied (p<0.05) depending on age, experiences of insurance education and average hours of education. The longer average hours of education, the higher level of practical application. Experiences of insurance education turned out to affect on the knowledge of health insurance standard significantly (p<0.05) on the part of dentists and insurance claim personnel, and the level of experiences in insurance claim and knowledge of health insurance standard on the part of dentists and insurance claim personnel turned out to affect on practical application significantly (p<0.001). Judging from the result, continuous education needs to be conducted in order to enable dentists and insurance claim personnel to maintain the level of knowledge about health insurance and practical application.

• Journal of the Korean hospital association
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• v.36 no.4 s.308
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• pp.49-56
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• 2007

• The Korean Society of Law and Medicine
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• v.14 no.2
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• pp.11-41
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• 2013

Article 347 of criminal law provides the act of deceiving another, thereby taking property or obtaining pecuniary advantage from another. On the other hand, the concepts of fraud and abuse are confused upon interpretation since the definition in National Healthcare Insurance Law is unclear, and it affects closely to the administrative measures such as surcharge levy by the period of inspection, therefore, the disputes continue in the forms of formal objection, administrative ruling and administrative litigation. This study aims to look over the legal problems on application of criminal fraud toward the abuse of 'Paid Medical Expenses(Article 57, Sections 1 and 4 of the National Health Insurance Act)'. The main issues are concept of abuse(Article 57, Sections 1 and 4 of the National Health Insurance Act), the problems of Directions of Health-Welfare Ministry on aspect of 'Nullum crimen sine lege' Principles, the proper sentenc-ing guidelines of fraud.

• The Korean Journal of Applied Statistics
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• v.27 no.5
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• pp.667-679
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• 2014

National Health Insurance Service(NHIS) provide care-plans for beneficiaries in the long-term care insurance(LTCI) systems that help them use LTC services appropriately. The care-plan includes recommendations for the most adequate type of care (gold standard) for beneficiaries. This study develops a decision-support system to determine the appropriate type of care plan. To develop a model, we used a data set that well-trained assessors in the NHIS investigated as a gold standard for beneficiaries: nursing home care, home-visit care, home-visit bathing, home-visit nursing, or day and night care. The decision-support system was established through a decision-tree model, because it may be easy to explain the algorithm of a decision-support system to working groups and policy makers. Our results might be useful in evidence-based care planning in an LTCI system and contribute to the efficient use of LTC services.

• The Journal of the Korean dental association
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• v.41 no.12 s.415
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• pp.814-815
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• 2003

• The Korean Society of Law and Medicine
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• v.16 no.2
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• pp.131-157
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• 2015

NHIS claimed for damages to doctors that by doing the treatment breaching medical insurance criteria caused by doctors, NHIS paid for medicine cost to pharmacy; as a result, the doctors caused the tort to NHIS. Following consecutive rulings afterwards, NHIS also argued that the medicine cost violating medical law or medical treatment expense paid to medical organizations are both the tort in civil law. NHIS claimed for all the damages, and the Supreme Court confirmed this judgment. However, within our national health insurance system, the subject of insurance payment is NHIS and the subject of medical treatment expense are also NHIS since the treatment expense is also insurance payment by asking the treatment to medical organizations. Further, national health insurance law is not made to control the violation of medical treatment cases; therefore, the breach of medical law cannot be covered by illegality of tort in civil law regarding NHIS. If that is the case, in the case that if the patients are treated according to treatment criteria via the doctors delegated the doctors' permission by Health and Welfare minister, NHIS acquired the benefits to remove the duty to give treatment payment to doctors in civil law; thus, even though the doctors have breached the medical law, NHIS does not have any damages. The fact that supreme court confirmed the ruling that the treatment is the tort in civil law towards NHIS is the judgment not counting the benefits of insurance payment as the subject but only considering the fact that NHIS paid to the doctors and this ruling have gone against the principle under civil code section 750. If the doctors have breached the medical law, the case should be sanctioned by medical law not national health insurance law, and the ruling of supreme court is assumed that they have confused both with the principle of national health insurance law and civil law.

• The Korean Society of Law and Medicine
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• v.13 no.2
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• pp.45-72
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• 2012

The National Health Insurance Corporation has been retrieving from health care providers the payments made to them by insured patients as a result of the health care providers' arbitrary denial of coverage under the National Health Insurance, and has been disbursing such retrieved monies back to the patients, pursuant to Article 57, Sections 1 and 4 of the National Health Insurance Act. However, such practice is an application of the law that lacks legal exactitude. Another problem with such practice is that there is no legal provision under any laws or notices that expressly prohibits arbitrary denial of coverage. A legislative solution, therefore, is called for to address these issues.

• Journal of Internet of Things and Convergence
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• v.8 no.2
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• pp.13-24
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• 2022

In order to explore the context of fraudulent claims and the measures for preventing them targeting the long-term care institutions for the elderly, which is increasing every year in Korea, this study conducted the text mining analysis using the media report articles. The media report articles were collected from the news big data analysis system called 'BIG KINDS' for about 15 years from July 2008 when the Long-Term Care Insurance for the Elderly took effect, to February 28^th 2022. During this period of time, total 2,627 articles were collected under keywords like 'elderly care+fraudulent claims' and 'long-term care+fraudulent claims', and among them, total 946 articles were selected after excluding overlapped articles. In the results of the text mining analysis in this study, first, the top 10 keywords mentioned in the highest frequency in every section(July 1^st 2008-February 28^th 2022) were shown in the order of long-term care institution for the elderly, fraudulent claims, National Health Insurance Service, Long-Term Care Insurance for the Elderly, long-term care benefits(expenses), elderly care facilities, The Ministry of Health & Welfare, the elderly, report, and reward(payment). Second, in the results of the N-gram analysis, they were shown in the order of long-term care benefits(expenses) and fraudulent claims, fraudulent claims and long-care institution for the elderly, falsehood and fraudulent claims, report and reward(payment), and long-term care institution for the elderly and report. Third, the analysis of TF-IDF was similar to the results of the frequency analysis while the rankings of report, reward(payment), and increase moved up. Based on such results of the analysis above, this study presented the future direction for the prevention of fraudulent claims of long-term care institutions for the elderly.

• Proceedings of the Korean Operations and Management Science Society Conference
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• 2008.10a
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• pp.342-345
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• 2008

산재 발생 시 산재근로자는 근로복지공단을 통해서 각종 급여를 받게 된다. 본 논문은 심사 과정과 급여지급 후에 부정수급으로 판명된 산재 청구 건을 데이터 마이닝을 통해서 분석하여 부정수급의 유형을 발견하고자 한다. 이 연구에서는 서울관내 4개 지사에서 8년 동안(2000년$\sim$2007년)의 총 61,536명의 최초요양 신청을 한 산재근로자 자료를 대상으로 하였고, 종속변수에 영향을 미치는 8개의 독립변수를 선택해서 사용한다. 데이터 마이닝을 적용함에 있어서 가장 효율적인 허위 부정 탐지 모델을 만들기 위해 의사결정나무분석(Decision Tree)과 로지스틱 회귀분석(Logistic Regresion)등의 다양한 기법을 적용하여 결과를 비교분석 하고, 오분류 비용을 적용하여, 최적의 분류결정 값을 가지는 모델을 도출한다. 분석결과, 로지스틱 회귀분석이 산재보험 부정수급 유형 발견에 보다 효과적인 모델로 판명되었다. 또한 판별점(Cut-Off) 0.01로 했을 때 4개변수(요양기간, 업종형태, 의료기관, 재해발생형태)가 부정수급에 탐지하는데 영향력이 큰 변수로 선정되었다.