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입원적정성 심사 효율화 방안 연구용역

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Type
Research report
Author(s)
차현숙이동현강현철이준서백옥선강태현이우진
Issued Date
2022-12
Publisher
건강보험심사평가원
URI
https://repository.hira.or.kr/handle/2019.oak/3106
Table Of Contents
요약 ···························································································· ⅲ

제1장 서론 3
Ⅰ. 연구 필요성 및 목적 ············································································· 3
1. 연구 필요성 ································································································ 3
2. 연구 목적 ··································································································· 7
Ⅱ. 연구내용 및 방법 ·················································································· 7
1. 주요 연구내용 ····························································································· 7
2. 연구방법 ··································································································· 11
Ⅲ. 기대효과 및 활용방안 ·········································································· 14
1. 기대효과 ··································································································· 14
2. 활용방안 ··································································································· 14

제2장 입원적정성 심사 현황분석 19
Ⅰ. 입원적정성 심사 건의 변화 ··································································· 19
1. 건강보험심사평가원의 입원적정성 심사 현황 ················································· 19
2. 입원적정성 심사의뢰기관에 따른 현황 ·························································· 21
3. 입원적정성 심사 결과 등의 현황 ································································· 23
Ⅱ. 금융감독원 자료에 따른 보험사기 현황 ·················································· 25
1. 보험종류에 따른 적발실적 현황 ··································································· 25
2. 사고내용에 따른 보험사기 적발현황 ····························································· 26
3. 입원적정성 심사와 연관한 보험사기 현황 ····················································· 33
Ⅲ. 보험사기를 통한 사회적 비용의 발생 ····················································· 34
1. 보험사기 적발을 위한 수사인력의 소모와 비용의 추정 ··································· 34
2. 실손보험료를 통해 추정가능한 일반국민의 추가적인 보험료 부담 ···················· 36
Ⅳ. 입원적정성 심사 효과성 분석 ································································ 39
1. 입원적정성 심사 효과성 분석의 방향 ··························································· 39
2. 법원 판례 자료에 따른 입원적정성 심사의 효과성 분석 ································· 40
3. 금융감독원 자료에 따른 입원적정성 심사의 효과성 분석 ································ 43

제3장 주요 국가의 보험사기 사례 47
Ⅰ. 미국의 보험사기 감독기관 ···································································· 47
1. 법률적 근거 ······························································································ 47
2. 주요 기관의 역할 ······················································································· 48
3. NICB의 운영과 예산 ·················································································· 50
Ⅱ. 영국의 보험사기 감독기관 ···································································· 53
1. 법률적 근거 ······························································································ 53
2. 주요 민간기관과 역할 ················································································· 54
3. NHS관련 사기전담기관과 역할 ···································································· 56
Ⅲ. 프랑스의 보험사기 감독기관 ································································· 57
1. 법률적 근거 ······························································································ 57
2. 주요 기관과 역할 ······················································································· 57
Ⅳ. 국외 사례를 통한 주요 시사점 ······························································ 58
1. 정보공유체계의 구축 ·················································································· 58
2. 별도의 기금을 통한 지속적인 운영형태 ························································ 59

제4장 입원적정성 심사의 개선방안 63
Ⅰ. 입원적정성 심사 상의 문제와 개선방향 ·················································· 63
1. 지속적인 입원적정성 심사 처리 일수의 증가문제 ··········································· 63
2. 입원적정성 심사 인력 부족의 해결 ······························································ 64
3. 보험사기 관련 자료 공유 체계 부재에 따른 협력체계의 구축 ·························· 67
4. 인력확보를 위한 추가적인 예산지원 ····························································· 68
Ⅱ. 입원적정성 심사의 개선방향에 따른 로드맵 ············································ 70
1. 입원적정성 심사 개선을 위한 단계적 목표의 설정 ········································· 70
2. 관련 법률의 개정과 예산 및 인력 확보를 중심으로 한 단기적 개선방안 ·········· 71
3. 독립적인 업무수행 심사체계 및 관계기관 정보공유체계 구축의 중기적 목표 수립 ··· 73
4. 지속적인 효과성 분석과 공유자료의 산출, 건강보험심사평가원의 업무 연계 ····· 76

제5장 입원적정성 심사 관련 법령 정비방안 및 주요내용 해설 81
Ⅰ. 입원적정성 심사 효율화를 위한 법령 정비 방향성 검토 ··························· 81
1. 건강보험심사평가원의 업무와 입원적정성 심사 ·············································· 81
2. 입원적정성 심사 관련 법령 정비의 필요성 및 배경 ······································· 83
3. 입원적정성 심사 관련 비용 지급 근거 규정 정비방안 ···································· 86
Ⅱ. 입원적정성 심사 효율화를 위한 절차 등 규정 방식 ································· 90
1. 입원적정성 심사 관련 절차 규정 방식 검토 ·················································· 90
2. 「보험사기방지 특별법」상 관련 절차 근거 규정안 ··········································· 92
Ⅲ. 입원적정성 심사 관련 근거 규정 신설에 따른 하위법령안 ························ 95
1. 제명 ········································································································· 95
2. 목적 규정 ································································································· 95
3. 심사의 원칙 규정 ······················································································· 96
4. 입원적정성 심사의뢰 ·················································································· 97
5. 입원적정성 심사 ························································································ 99
6. 공공심사위원회 ························································································ 100
7. 공공심사위원회의 규정 ············································································· 102
8. 위원회의 운영 ························································································· 103
9. 위원의 해임⋅해촉 ··················································································· 106
10. 관계자 의견 청취 및 자료 제출 등 ·························································· 107
11. 위원의 제척⋅기피⋅회피 ········································································ 108
12. 수당 등의 지급 ······················································································ 109
13. 입원적정성 심사 관련 자료의 제공 요청 ··················································· 111
14. 사건 종결 시 결과 회신 ········································································· 112
15. 운영규정 ······························································································· 113
Ⅳ. 입원적정성 심사 발전 로드맵 관련 법령 개정 등 입법 검토 사항 ··········· 114
1. 단기ㆍ즉시적 검토 사항 ············································································ 114
2. 중장기적 검토 사항 ·················································································· 114

제6장 기타 검토 사항 117
Ⅰ. 기타 검토 사항 1: 입원적정성 심의 결과에 대한
증거 능력 부인 판결 관련 검토 ······························ 117
Ⅱ. 기타 검토 사항 2: 「보험사기방지 특별법」 관련 국회 제출 법률안 분석 ·· 120

◾ 참고 문헌 ····················································································· 125
◾ 부록 ····························································································· 126
Publisher
건강보험심사평가원
Location
KOR
Citation
차현숙. (2022-12). 입원적정성 심사 효율화 방안 연구용역.
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