HIRA

요양급여 청구 부당사례 모음집

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Type
Book
Author(s)
건강보험심사평가원
Issued Date
2023-03
Publisher
건강보험심사평가원
URI
https://repository.hira.or.kr/handle/2019.oak/3143
Table Of Contents
Ⅰ. 현지조사 개요 ········································································· 1
1. 현지조사 개요 ································································································· 3
2. 조사대상기관 선정 과정 ················································································ 5
3. 업무처리 절차 ································································································· 6
4. 조사 결과에 따른 처분 ·················································································· 7
5. 부당청구 ·········································································································· 9
6. 거짓청구 ········································································································ 15
7. 현지조사 부당사례 등 조회 방법 ······························································· 17

Ⅱ. 부당청구 유형별 사례 ························································· 19
1. 거짓청구 ········································································································ 21
가. 입・내원(내방)일수 거짓 및 증일청구 ····························································· 22
나. 비급여 대상 진료 및 청구 후 요양급여비용 이중청구 ································ 25
다. 실제 진료(투약)하지 않은 행위 등을 거짓청구 ············································ 28
라. 무자격자가 실시한 진료비(약제비)거짓청구 ·················································· 34
마. 의료행위 증량 청구 ·························································································· 38
바. 면허증 대여 등으로 인력신고 후 요양급여비용 거짓청구 ·························· 39
2. 산정기준 위반청구 ······················································································· 41
가. [행위] 산정기준 위반청구 ················································································ 42
나. [약제・치료재료] 산정기준 위반청구 ······························································· 62
다. 요양기관 외 진료 등 산정기준 위반청구 ······················································ 65
라. 차등수가 기준 위반청구 ·················································································· 68
마. 비급여 대상을 진료하고 요양급여비용으로 청구 ········································· 70
3. 행위료・의약품・치료재료대 등 대체청구 ···················································· 71
가. 행위료・의약품 등 대체청구 ············································································· 72
나. 의약품・치료재료대 실사용량 초과청구 ·························································· 76
4. 본인부담금 과다징수 ···················································································· 77
가. 의약품 비용 과다징수 ······················································································ 78
나. 수가고시 행위료(기준액 이상 등) 부당징수 ·················································· 79
다. 재료대비용 부당징수 ························································································ 82
라. 상급병실료 부당징수 ························································································ 84
마. 결정고시 이전의 신의료기술 등 ····································································· 85
바. 기타 과다징수 ··································································································· 86
5. 기타 부당청구 ······························································································· 89
가. 미근무, 비상근 인력에 따른 부당청구 ··························································· 90

Ⅲ. 부당사례 관련 법규 ························································ 103
 국민건강보험법 ··························································································· 105
 국민건강보험법 시행령 ·············································································· 107
 국민건강보험 요양급여의 기준에 관한 규칙 ·········································· 123
 의료법 ·········································································································· 129
 의료법 시행규칙 ························································································· 131
 약사법 ·········································································································· 132
 의료기사 등에 관한 법률 ·········································································· 135
 의료기사 등에 관한 법률 시행령 ····························································· 136
Publisher
건강보험심사평가원
Location
KOR
Citation
건강보험심사평가원. (2023-03). 요양급여 청구 부당사례 모음집.
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