Fraudulent medical claims in Korea hit ₩116.1 bil. over five years

The amount of fraudulent claims uncovered at medical institutions over the past five years has reached 116.1 billion won ($83.5 million). Notably, some medical institutions continued illegal practices even after receiving business-suspension penalties, only to be caught again, according to the data.

According to data submitted to Rep. Ahn Sang-hoon of the People Power Party by the Health Insurance Review and Assessment Service (HIRA) last Friday, fraudulent claims by healthcare facilities totaled 116.15 billion won from 2020 to August 2025. The amount surged to 37.8 billion won in 2024, more than five times the 2020 figure (7.6 billion won).

By type of fraudulent claim, unjustified claims violating Ministry of Health and Welfare notices and calculation standards totaled 19 billion won, the highest amount in 2024.

It was followed by false claims, where documents were forged or altered to claim medical benefits despite no actual treatment taking place, amounting to 10.3 billion won; substitution claims, where procedures, medications, or treatment materials different from the actual treatment were billed, totaling 1.8 billion won; and overcharging of patient copayments, where excessive copayments were collected despite services being non-covered items, amounting to 1.1 billion won.

Regarding reporting channels for fraudulent claims, referrals through HIRA were the most common over the past five years, totaling 2,200 cases, followed by the National Health Insurance Service (NHIS) with 833 cases and the Ministry of Health and Welfare with 282 cases.

Furthermore, during compliance inspections of medical institutions suspended for fraudulent claims, 98 cases were uncovered in which institutions secretly continued to provide services. The fraudulent claims from these cases totaled approximately 2.15 billion won.

Rep. Ahn pointed out that the scale of fraudulent claims by medical institutions has reached 116.1 billion won and is rapidly increasing every year, yet the government's response remains lukewarm.

“The fact that institutions receiving suspension orders continue to operate illegally year after year is clear evidence that current sanctions and post-enforcement management are failing,” Ahn said. “To protect national health insurance finances, it is absolutely necessary to expand substantive on-site inspections, establish a permanent monitoring system, and impose strong penalties on institutions that commit intentional or repeated violations.”