When Blocked, Another Emerges... The Unending Background of 'Non-Covered Service Commercialization' [Leakage of Indemnity Insurance Payments]④

Recommended manual therapy for child's flat feet... insurance claim denied
Verbal recommendation for Mammotome surgery citing high cancer risk
Referral form actually altered in documentation

Various non-reimbursable items created by hospitals are a kind of whack-a-mole game. When a popular non-reimbursable treatment becomes problematic and is blocked, another non-reimbursable item is created. Even for ordinary diseases that do not require non-reimbursable treatment, non-reimbursable options are recommended as much as possible. Doctors, insurance planners, and brokers even hold study meetings to develop ingenious non-reimbursable items. A few years ago, Gangnam A Eye Clinic, which made a so-called "jackpot" from cataract surgery, is rumored to have earned a lifetime's worth of income for an ophthalmology clinic in less than five years. This is why everyone is eager to develop new ideas for non-reimbursable treatments.

When the medical logic for non-reimbursable treatments goes too far, absurd treatment methods sometimes emerge. Recently, domestic B General Insurance received a ridiculous claim for indemnity insurance from a large hospital in Incheon, where manual therapy was being performed to improve the flat feet of an 8-year-old child named C. C visited the hospital due to symptoms of the ankle bending inward and received 23 sessions of manual therapy over about six months. B General Insurance had never encountered manual therapy for pediatric flat feet before, so they sought medical advice to make a medical judgment regarding the treatment.

The result was a denial of indemnity coverage for the entire manual therapy. The medical advisor responded, "Flexible flat feet should be treated with active exercise, not manual therapy," and recommended an investigation into the doctor at the hospital. Ultimately, the patient's parents trusted only the hospital doctor's advice, underwent manual therapy, and ended up bearing abnormal treatment and huge medical expenses. A B General Insurance official said, "We only sought a simple medical judgment, but the fact that the medical advisor, who is also a medical professional, recommended an investigation indicates that it went too far," adding, "Cases where diseases are forcibly linked to non-reimbursable treatments will continue in the future."

A patient receiving manual therapy. The photo is unrelated to the content.

There was also a trick where, after recommending non-reimbursable treatments that patients did not need to pay for, when the patient said they wanted to get additional examinations at a higher-level hospital, the diagnosis was slyly changed only on paper. Kim Ji-yeon, a woman in her 30s, recently discovered a 3 cm lump through a breast ultrasound and underwent a biopsy at D Surgery Clinic located in Gwangmyeong, Gyeonggi Province. The doctor at D Surgery Clinic diagnosed atypical hyperplasia and said the shape was poor and there was a high possibility of developing into cancer, so she needed to undergo a Mammotome surgery quickly. Mammotome is a device that uses ultrasound to visualize the lesion and inserts a special needle to excise the tumor. The price is about 2 million KRW as a non-reimbursable treatment.

Kim wanted to get a second opinion at a large hospital, so she did not schedule the surgery and obtained a referral letter before visiting Gangnam St. Mary's Hospital. After re-examining the biopsy results at St. Mary's Hospital, the diagnosis was a simple fibroadenoma that did not require surgery. When the doctor at St. Mary's Hospital said, "It's not severe enough to require surgery; let's monitor the progress," Kim asked to recheck the referral letter she received from D Surgery Clinic. The referral letter, written in technical terms and English, did not mention "atypical" and instead described the shape as good. D Surgery Clinic verbally scared Kim and forced non-reimbursable treatment, but the documents for the higher-level hospital contained normal medical opinions.

The prevalence of unreasonable non-reimbursable treatments is due to the huge profits they bring. Research also shows that the higher the proportion of non-reimbursable treatments, the higher the income of specialists. According to a paper titled "Correlation between Specialty Residency Application Rates, Physician Income, and Non-Reimbursable Rates by Specialty" (Jung Eun-young, Na Young-gyun), published in the Korean Citation Index (KCI) in March, the highest average annual income for specialists in 2020 was ophthalmology at 458.37 million KRW. This was followed by orthopedics (402.84 million KRW), rehabilitation medicine (379.93 million KRW), neurosurgery (370.65 million KRW), and dermatology (302.63 million KRW). These top five specialties also had high proportions of non-reimbursable treatments. As of 2021, rehabilitation medicine had the highest non-reimbursable rate at 42.6%, followed by ophthalmology (42.3%), orthopedics (36%), neurosurgery (35.3%), and pediatrics (25.3%).