[Exclusive] Trying to Claim Cataract Insurance... Creating Complications and Altering Medical Records at Gangnam Eye Clinic

Continued Fraudulent Non-Covered Insurance Claims for Cataract in Gangnam
Intentional Intraocular Pressure Increase Suspected... Dual Medical Records Alleged
Major Insurers Plan Joint Response

Despite a reduction in excessive non-reimbursed cataract treatments following stricter insurance payout criteria and supporting Supreme Court precedents, some ophthalmology clinics in the Gangnam area of Seoul still engage in rampant cataract 'insurance shopping.' These clinics have employed increasingly sophisticated methods that sometimes cause complications, while also omitting certain documents submitted to insurance companies.

According to insurance claim data related to Gangnam B Ophthalmology Clinic obtained by Asia Economy from a major non-life insurer A on the 8th, B Ophthalmology Clinic diagnosed nearly all cataract patients this year with postoperative intraocular pressure (IOP) elevation complications. They proceeded with inpatient treatment and claimed insurance payouts amounting to several million won per person from the insurer. In June last year, the Supreme Court recognized outpatient treatment as the principle for cataract surgery, allowing inpatient treatment only as an exception when continuous medication or procedures are required due to postoperative complications.

Suspiciously Elevated Intraocular Pressure After Cataract Surgery

According to insurer A’s verification, all patients who claimed high-value cataract insurance payouts at this hospital underwent medical procedures such as posterior capsulotomy due to posterior capsule rupture, vitrectomy due to vitreous prolapse, and anterior chamber paracentesis to lower intraocular pressure. Unusual elevations in IOP were also detected. B Ophthalmology Clinic considered these as complications and treated them as requiring inpatient care.

The problem is that these symptoms appear unnatural. Patients who underwent cataract surgery at B Ophthalmology Clinic commonly exhibited IOP levels around 70 mmHg. Considering research findings that the frequency of IOP elevation above 22 mmHg one day after cataract surgery is 30.7%, and above 30 mmHg is 8.9%, these levels are excessively high.

Regarding this, C University Hospital, which provided medical consultation to insurer A, stated, "Almost all cataract patients consulted from this hospital showed significant postoperative IOP elevation," adding, "Such a degree of IOP elevation warrants hospitalization, but it is quite rare for one ophthalmologist to observe such high IOP elevations consecutively unless intentional." They further noted, "Unless the elevation is intentionally induced by leaving viscoelastic substances, the reliability of the IOP measurements is questionable." Another medical expert explained, "Leaving viscoelastic substances to raise IOP to this extent is a risky act that could lead to glaucoma and would impose a considerable burden on patients."

According to medical records received by insurer A, B Ophthalmology Clinic administered a drug called 'mannitol' to lower the elevated IOP in patients showing abnormal IOP symptoms. Mannitol is typically used to reduce intracranial pressure in patients with cerebral hemorrhage. Before administration, blood tests are usually conducted to check osmotic pressure levels and sodium and potassium levels. After administration, saline is also given while monitoring various blood parameters. However, the patients’ medical records only noted the administration of mannitol, with no records of these additional measures. Insurer A’s investigation revealed that patients also had no recollection of such procedures.

Evidence of Fabricated Medical Records... CT Scan Costs 70 Times Higher

There are also suspicions of forged documents. When insurer A requested medical records with patient consent, the materials submitted by B Ophthalmology Clinic contained no mention of elevated IOP. However, the medical records provided by patients, obtained from their doctors, did include details of IOP elevation. This suggests that separate medical records were fabricated for patient use and for submission to insurance companies.

Notably, B Ophthalmology Clinic selectively performed non-reimbursed surgeries only on policyholders who enrolled in indemnity insurance before January 2016, when multifocal lenses for cataract surgery became covered. According to the Health Insurance Review & Assessment Service, last year the non-reimbursed price for multifocal lenses used in cataract surgery varied widely between medical institutions, ranging from a minimum of 330,000 won to a maximum of 9 million won, a 27-fold difference. Additionally, B Ophthalmology Clinic set the cost of optical coherence tomography (OCT) at 6.1 million won (per eye), which is 70 times higher than the average OCT cost of 86,693 won at ophthalmology clinics in Seoul according to the Health Insurance Review & Assessment Service.

By conducting inpatient treatment based on complications from elevated IOP, B Ophthalmology Clinic has received approximately 250 million won in insurance payouts this year from major insurers including Samsung Fire & Marine Insurance, Hyundai Marine & Fire Insurance, KB Insurance, and DB Insurance. This amount is double the average outpatient revenue of 122.14 million won for ophthalmology clinics in the first half of last year.

Insurance companies are planning a joint response to these ophthalmology clinics. Special Investigation Units (SIUs) from various insurers have requested investigations into B Ophthalmology Clinic and other nearby clinics in Gangnam. They have already confirmed evidence of manipulated medical records in addition to the elevated IOP cases. A representative from a major insurer stated, "Several insurers are focusing on B Ophthalmology Clinic and other nearby clinics in Gangnam," adding, "Once preparations are complete, we will proceed with joint investigations and responses."