Thorough Management of Patient History and Treatment Records During Investigation of Insurance Fraud and Medical Malpractice
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In cases where investigations are conducted by the National Health Insurance Corporation or the police due to malpractice or excessive or fraudulent treatments, investigators will pursue evidence collection and analysis to question the accused. How should one prepare for such situations?
Identifying Fraudulent Hospital Admissions and Treatment
Based on my experience, when investigating fraudulent hospital admissions, the Health Insurance Review and Assessment Service verifies admission details through various means, such as credit card transaction records, traffic violation data, transportation card usage, bank account transaction records, and hospital CCTV footage. Typically, patients who do not require hospitalization may falsely pose as admitted patients, and a follow-up investigation is necessary to confirm the patient's admission status.
Insurance Fraud and Excessive Claims
In cases of typical insurance fraud, where patients hospitalized for minor illnesses (that do not require hospitalization) make multiple insurance claims across several companies, the Health Insurance Review and Assessment Service may issue a review suggesting that the length of hospitalization is excessive. This prompts law enforcement to investigate the potential collusion between the patient and the hospital.
Verification of Fraudulent Admissions
For fraudulent admissions, investigators will cross-check whether patients actually stayed in the hospital or lived outside through credit card usage, mobile phone records, and bank statements. These facts are confirmed through asset tracking and search warrants issued by the authorities.
Investigating Medical Records for Proof of Diagnosis and Treatment
When law enforcement receives tips regarding insurance fraud, they will request relevant materials from the Health Insurance Review and Assessment Service, the Medical Association, insurance companies, hospital associations, and the Workers' Compensation and Welfare Corporation. These materials include medical records to verify the actual diagnosis, such as personal details, medical conditions, and individual examinations.
Verifying Treatment and Medications
To verify the treatment and medication details, investigators will examine physical therapy records (including treatment methods, patient responses, treatment times, and signatures of therapists), medication records (including details of drugs prescribed, dates, and times), and payment receipts for medical expenses (to confirm the actual payment of treatment costs by the patient).
Importance of Detailed Documentation of Medical Records
To prevent any disputes regarding false diagnoses or treatments, careful and truthful documentation of examination and treatment records is essential. In addition, if there is any doubt about whether the patient fully understood the doctor's explanation, obtaining the patient's written consent or signature is crucial.
Clear and Thorough Documentation for Treatment and Medication
Rather than using complex medical terminology, it is recommended to use illustrations or related images to explain symptoms and the necessity of procedures. Furthermore, when prescribing medications, clear explanations of the drug's efficacy and dosage should be provided, and the patient should confirm they understood this explanation.
Cooperation with Authorities to Combat Insurance Fraud
As insurance fraud schemes become increasingly sophisticated (e.g., patients moving between multiple hospitals for long-term stays, using burner phones and bank accounts to avoid detection), law enforcement, the National Health Insurance Corporation, and the Health Insurance Review and Assessment Service collaborate to track and investigate related data carefully.
Consequences of Involvement in Insurance Fraud
I have witnessed some doctors who, tempted by brokers involved in insurance fraud, ended up being investigated and faced significant penalties, including criminal charges, the recovery of unjustified insurance payments, and the revocation of their medical licenses. These doctors were unable to continue their medical careers.
Preventing False Accusations of Fraud or Medical Malpractice
To avoid wrongful accusations of insurance fraud, excessive or misdiagnosed treatment, it is essential to maintain meticulous medical records and ensure proper patient notifications, explanations, and consent are documented thoroughly.
Avoiding Destruction of Evidence
It is important to be aware that if any evidence is hidden, destroyed, or tampered with during the investigation process, the responsible parties may be charged with obstruction of justice, leading to criminal penalties or even detention.
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