국민건강보호법의 최근 이슈들 ; 요양기관 현지조사제도에 관한 법적 고찰 = A Legal Study on the administrative investigation of medical institution

다국어 초록 (Multilingual Abstract)

Administrative investigation of medical institution was set that MOHW(Minister of Health and Welfare) could order to report or submit the documents on the reimbursements of medical care and drug dispensing, or the officers in charge could ask to the relevant persons or inspect the related documents, upon Section 2 of Article 84 in National Healthcare Insurance Law. If the medical institution claims the reimbursement with cheating or other inappropriate manner, the administrative measure would be executed based on Article 85, Article 85-2 of National Healthcare Law and Article 61 of Enforcement Ordinance. However, the concept of fraud is confused upon interpretation since the definition in 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. Considering the purpose of investigation of medical institution is to contribute to maintain the sustainable healthcare security system to protect the members of healthcare insurance and sound healthcare providers, and to prevent unnecessary monetary leakage by developing sound environment of reimbursement claims and encouraging appropriate medical cares, legality, transparency, and rationality should be considered. This study aims to look over the significance of current investigation of medical institution, and its type, procedure of conducting investigation, and legal rationales, and to discuss on the significance of general administrative investigation, and its legal limitations, saving rights, and the cases of administrative litigation. Administrative investigation is essential to set up desirable policy and to make administrative decisions. however, it has the potential to disturb the right and freedom of the people. Unlike judicial investigation, administrative investigation has inadequate control system such as legal procedure, at the same time, it has been conducted with the functions of criminal investigation and restrictions beside the original purposes in the practice.