As a result of investigating some elderly long-term care facilities, it was found that 94% of them falsely claimed care benefit costs over the past five years.
According to the National Health Insurance Service, from 2019 to last month, a total of 5,988 long-term care institutions were selectively investigated, and improper claims were detected in 5,611 institutions (93.7%). The total amount detected was 236.56 billion KRW.
Long-term care institutions provide long-term care benefits, which refer to services such as nursing care or cash given instead to elderly individuals recognized as having difficulty performing daily activities alone for more than six months.
Each local government conducts on-site investigations to ensure appropriate benefit claims and transparent operational environments at long-term care institutions, and the Health Insurance Service supports these efforts with personnel and other resources.
The institutions investigated this time were not all long-term care institutions but were selected based on high likelihood of fraudulent claims using various methods such as the big data-based Fraud Detection System (FDS).
The amount of improper claims has continuously increased during the investigation period, rising from 21.24 billion KRW (784 institutions) in 2019 to 66.68 billion KRW (676 institutions) last year, more than tripling. The detection rate from on-site investigations has remained around 90% annually.
However, among the 27,474 long-term care institutions that completed benefit claims and payments as of the end of last year, only 4.9% (1,342 institutions) were confirmed to have made improper claims. The amount of improper claims last year accounted for about 0.6% of the total benefits paid (10.6 trillion KRW).
Long-term care institutions operated or staffed by relatives of NHIS employees also falsely claimed benefits. According to the NHIS, there are about 280 such institutions nationwide where relatives of employees directly operate or work as secretaries-general or in similar positions. Among them, 189 were institution representatives, 80 were facility managers, and 11 were secretaries-general.
As of July this year, an investigation of 63 such long-term care institutions over the past five years found that all but four falsely claimed benefits, amounting to approximately 3.6 billion KRW. Consequently, these institutions were suspended from operations for a total of 1,783 days.
The NHIS regularly investigates the status of employees who are relatives within the fourth degree of kinship working or operating long-term care institutions and restricts personnel transfers in those regions accordingly.
Additionally, the NHIS is considering introducing a system that encourages long-term care institutions to autonomously inspect and report or return improperly claimed benefits once detected.
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