The effects of the fraud and abuse enforcement program under the National Health Insurance program in Korea

Abstract

Objective: To examine the general deterrence effect of the Korean government's fraud and abuse enforcement program on medical clinics in the country. The effects were evaluated by analyzing the association between the fear of penalty from a potential onsite investigation and the costliness index (CI).

Method: Using a stratified proportional systematic sampling method, 800 out of the 15,443 clinics in Korea that had not had an onsite investigation before June 2007 were selected. Perceived deterrence was measured via face-to-face interviews with the chief doctor of each clinic; these were conducted in July and August 2007. CI was calculated by dividing observed costs by expected costs based on National Health Insurance Claims from January to October 2007.

Results: Clinics with a high fear of penalty had a significantly lower CI than did other clinics after adjusting for factors related to the provider's perception of onsite investigation, the provider's service experiences, and general characteristics such as provider's sex and age.

Conclusion: Designing effective fraud and abuse control programs can improve the efficiency of providing services to patients.