[Legal Spotlight] ⑦ Strengthened Health Insurance Recovery and Administrative Disposition... "Early Response Determines a Hospital's Survival"

Attorney Jang Se-chang: "Be careful with statements of fact confirmation... Application for suspension of execution is also a key response"
A strategy of proving medical validity and contesting abuse of discretion is needed

Recently, as the National Health Insurance Service and investigative agencies have strengthened management and supervision of medical care benefit claims, the burden of administrative disposition on nursing hospitals and medical institutions is growing. Accordingly, systematic legal response from the on-site investigation stage is emerging as an important variable in hospital operations.

Jang Se-chang, attorney at Daeryun LLC, diagnosed on the 6th, "As surveillance and inspection standards for medical care benefit claims have been strengthened on the grounds of soundening health insurance finances, even medical institutions that provided normal treatment have become more likely to receive large medical care benefit recovery dispositions due to mere administrative errors."

Attorney Jang said that a recovery disposition does not simply end with paying back the recovered amount but can lead to imposition of penalty surcharges, business suspension, and criminal complaints, which can bring fatal consequences to medical institutions.

In such situations, he cited objectively proving the medical validity of the treatment as the most important response. He explained that one must clearly demonstrate it was not intentional false claiming but a mere administrative error, and that Supreme Court precedent—holding that recovering the full medical care benefit even for medical acts that actually contributed to patient treatment may constitute deviation from or abuse of discretion—should also be actively utilized.

In particular, he pointed out that the response at the on-site investigation stage is a key factor determining the direction of the case.

Attorney Jang said, "On-site investigations are mostly conducted without notice, so medical institutions tend to become psychologically intimidated," adding, "If asked to write a statement of fact confirmation during the investigation, one must not sign it without sufficient review."

He advised, "Since a statement of fact confirmation is later used as important evidence in administrative litigation, there are quite a few cases of writing it based only on the investigator's explanation or of an employee writing disadvantageous content beyond the scope of their duties," and "If there is room for dispute over the facts, only objective facts should be carefully recorded."

He also emphasized that when one has already received notice of a recovery disposition, an application for suspension of execution should be pursued in parallel with administrative litigation.

Attorney Jang explained, "Since administrative litigation can take several years until a final ruling, if suspension of execution is not accepted, medical care benefit payments may be withheld or property seized, making hospital operation itself difficult," and "Suspension of execution, which temporarily suspends the effect of the disposition, is a key means for a medical institution to maintain normal operations while continuing the legal dispute."

He added, "The outcome of a health insurance recovery case can vary greatly depending on the early response," and "It is important to prepare a response strategy together with a legal expert equipped with expertise in the medical and administrative fields from the early stage of the case."

Reporter Jeong Ye-jin yejin0311@inews24.com

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[Legal Spotlight] ⑦ Strengthened Health Insurance Recovery and Administrative Disposition... "Early Response Determines a Hospital's Survival" (Go to link)