우리나라 원격의료에서 제기되는 보험급여(Reimbursement) 문제에 관한 법적 연구 ― 미국 조지아 주(州)의 사례를 중심으로 ―

김항중 서울시립대학교 서울시립대학교 법학연구소 2019 서울법학 Vol.27 No.3

Reimbursement systems should be effectively modified and removed as a huge legal obstacle to widely expand the practice of telemedicine along with physician licensure, credentialing/privileging, telemedical malpractice, and privacy concerns. Reimbursement is the key to increasing medical access, reducing medical costs, and improving the quality of care so that more consistent and comprehensive policies are required to promote telemedicine across state lines. Favorably designed reimbursement policy encourages the practice of telemedicine services. Also, focusing on reimbursement in telemedicine is the key to ensuring the sustainability of telemedicine as a widely used practice. Appropriately balanced reimbursement system will provide a great opportunity for patients relying medically insufficient health care providers by providing better access, lower medical costs such as saving on transportation fees. Patients are able to expect improved quality of services. This article is going to focus on the fundamental structure of the reimbursement system. To do so, it is necessary to carefully overview the two major kinds of public health insurance Medicare(public health insurance program which provides medical services to those over 65 with different rates based on how much individual pays in taxes) and Medicaid(a joint Federal and State entitlement program which provides medical assistance for people who have low incomes regardless how much the individual pays in taxes) in the United States and private insurance because both public and private health insurance are important in reimbursement. In fact, the federal and state government tried to revise and change the current legal system to allow health care providers to receive reimbursement through Medicare and Medicaid. Most private insurance companies are waiting until the governments apply the reimbursement system for Medicare and Medicaid because most private health insurance companies set the reimbursement standard for coverage based on Medicare and Medicaid. Currently, the reimbursement system has some problems because reimbursement for telemedicine services is not widely allowed. The main reason is that there is no sufficient and exact information or data to evaluate costs, quality, and access in telemedicine. Actually, telemedicine services provide many benefits to the patients but telemedicine consultation has used and permitted reimbursement in only limited circumstances. However, many insurance companies are gradually allowing reimbursement in telemedicine services. I will overview how public health insurance such as Medicare and Medicaid and private insurers have handled reimbursement differently for the health care providers who properly provide telemedicine services to the patients by using defined information technologies. Additionally, I will specifically examine how the federal and state government tries to revise and change the existing legislative policies to allow reimbursement in Medicare and Medicaid as well. 의료보험의 보험급여 시스템은 의료인의 자격, 자격인증(자격심사검토)/특별인가, 원격의료에서의 의료과오 그리고 사생활 침해로 인한 프라이버시 우려와 함께 중요한 법적 장애물로 원격의료의 원활한 확대를 위해서는 반드시 효율적으로 수정되고 보완되어야 할 필요성이 있다. 보험급여는 의료접근성을 용이하게 하고, 의료비용을 절감할 수 있으며 더 나아가 의료의 질을 향상시킬 수 있는 핵심적 요소이므로 미국 전역에서 원격의료를 활성화하기 위해서는 일관성 있고 포괄적인 정책이 요구된다. 또한, 원격의료에 있어 보험급여에 중점을 두는 이유는 원격의료의 실행이 확대됨에 따라 원격의료의 지속성을 확보하기 위해서이다. 적절하게 균형 잡힌 보험급여 시스템은 건강관리 제공자의 수가 부족한 지역에서 그들에게 절대적으로 의존하고 있는 환자들에게 더 나은 의료접근성과 의료비용을 줄일 수 있는 기회를 제공함으로써 많은 편의와 이점을 제공해 줄 것이다. 따라서 환자들은 향상된 의료서비스를 기대할 수 있게 된다. 본 논문은 미국의 보험급여 시스템에 대한 근본적인 구조에 그 초점을 맞추고자 한다. 이를 위해 공적의료 건강보험의 성격을 띤 메디케어(Medicare)와 메디케이드(Medicaid) 그리고 사보험 회사들에 대해서 초점을 맞추어 전개하였다. 우선 메디케어(Medicare)는 공적 건강보험 프로그램으로서 65세 이상의 고령 은퇴자들에게 납부세금액수에 따라 차별화 된 혜택을 제공하는 공적 건강보험제도이다. 반면, 메디케이드(Medicaid)는 연방정부와 주(州)정부의 공동 프로그램으로 일정 소득 이하의 저소득층을 대상으로 의료비용을 지원해 주는 공적 건강보험제도이다. 단, 메디케이드(Medicaid)는 세금납부 여부와는 관계없이 의료비용을 지원받는다는 점에서 메디케어(Medicare)와는 구별된다. 사실 미국의 연방과 주(州)정부는 의사 및 건강관리 제공자들이 메디케어(Medicare)나 메디케이드(Medicaid)를 통하여 원격의료서비스에 대한 보험급여를 지급받을 수 있도록 현재의 법적 시스템을 일부 개정하고 수정하려는 노력을 지속적으로 진행하고 있다. 대부분 사보험 회사들은 정부가 메디케어(Medicare)나 메디케이드(Medicaid)에 어떻게 보험급여 시스템을 적용하는지를 주목하고 있는데 그 이유는 사보험 회사들이 메디케어(Medicare)나 메디케이드(Medicaid)에 근거하여 해당 보험급여 범위의 기준을 마련하기 때문이다. 현재 미국은 원격의료서비스에 대한 보험급여를 폭 넓게 인정하고 있지 않는데, 그 이유는 원격의료에 있어 비용, 의료의 질 그리고 접근성을 평가할 만한 정확하고 객관적인 충분한 정보나 자료가 부족하기 때문이다. 실제로 원격의료서비스가 환자들에게 많은 혜택을 제공하지만 단지 제한된 상황에서만 보험급여를 인정받고 있다. 그럼에도 불구하고 많은 사보험 회사들이 점차적으로 원격의료서비스에 대한 보험급여를 확대하려는 시도를 하고 있는 추세이다. 이하에서는 메디케어(Medicare)와 메디케이드((Medicaid) 그리고 사보험 회사들이 원격의료서비스를 제공한 의사 및 건강관리 제공자들에게 어떻게 각각 다른 보험급여를 지급해 왔는지 살펴보기로 한다. 또한, 미국의 연방과 주(州)정부가 원격의료에 있어 메디케어(Medicare)와 메디케이드(Medicaid)의 보험급여를 인정하기 위해서 관련 입법정책들을 어떻게 개정 그리고 수정하고 있는지 특히, 조지아 주(州)의 사례를...

자동차 리콜 전의 시정에 대한 보상제도

최성근 한국경제법학회 2010 경제법연구 Vol.9 No.1

This article deals with issues on the reimbursement for repairs prior to recall for motor vehicle safety. The reimbursement system was introduced by enacting Transportation Recall Enhancement, Accountability, and Documentation(TREAD) Act in U. S. in 2000. The Act provides at Section 6(b) that motor vehicle and motor vehicle equipment manufacturers are required to include in their recall programs to remedy a safety-related defect or a noncompliance with a federal motor vehicle safety standard, a plan for reimbursing owners for the cost of a remedy incurred within a reasonable time before the manufacturer's notification of the defect or noncompliance. The rule for implementing the Act was adopted in 2003. According to the rule, manufacturers are required to take certain actions to assure that owners or purchasers are appropriately aware of the possibility of reimbursement. In recalls where there is a reasonable likelihood that some persons may have made expenditures that are eligible for reimbursement, the manufacturer would have to include language in each owner notification that refers to such possible eligibility and that advises how to obtain the details on eligibility for reimbursement and how to obtain reimbursement. And the rule identifies the conditions that manufacturers may impose upon reimbursement. The reimbursement plan may, with some limitations, exclude reimbursement for costs incurred within the period during which the manufacturer's warranty would have provided for a free repair of the problem addressed by the recall. The rule also permits manufacturers to exclude reimbursement if the pre-notification remedy was not the same type of remedy as the one used in the recall, did not address the defect or noncompliance that led to the recall or a manifestation of the defect or noncompliance, or was not reasonably necessary to correct the defect or noncompliance. In Korea, the reimbursement system for repairs prior to recall for motor vehicle safety was introduced on the model of the U. S. system by the amendment of Automobile Management Act. The Korean system plays an important role in motor vehicle consumer protection, but it seems to have some problems, such as reimbursement period, the method for calculating the cost, and so forth. In this article, the Korean reimbursement system for repairs prior to recall for motor vehicle safety is analyzed, and its problems are indicated and the improvement schemes are proposed. 자동차 리콜제도란 자동차의 차체 또는 부속장치의 결함에 대해 자동차제작자 또는 부품제작자 등이 스스로 공개적인 수리, 회수 또는 환급을 하는 제도를 말한다. 자동차 리콜제도가 효과적으로 운용되려면 무엇보다도 기업의 자발적 참여가 필수적이다. 아울러 법제도의 정비도 병행되어야 하는데, 먼저 리콜의 대상범위를 명확히 할 필요가 있다. 이를 위해 리콜의 대상인 ‘결함’을 안전상의 하자로 한정하고, 그 밖의 하자는 품질상의 하자로서 제작사의 자발적인 고객서비스에 맡기는 것이 적절할 것이다. 2009년 미국의 제도를 모범으로 자동차 리콜 전 시정보상제도가 도입되어 현재 시행되고 있다. 자동차 리콜 전 시정보상제도란 자동차제작자 등이 자동차의 결함사실을 공개하고 수리하거나 부품을 교환해 주는 등의 시정을 하기 전에 자동차소유자 등이 자기의 부담으로 그 결함을 시정한 때에는 제작자 등이 그 비용을 보상하도록 하는 제도이다. 자동차 결함의 특성에 비추어 볼 때, 리콜 전 수리비용에 대한 보상제도는 민법상의 손해배상책임제도에 의한 소비자보호의 취약점을 보완하고, 리콜 적용대상자 간의 형평성을 제고하며, 리콜제도의 적기 적용을 유도하는 효과가 있으므로 도입이 적절하였다고 판단된다. 동제도의 시행 이후 이루어진 자동차 리콜의 통지 또는 공고에는 예외 없이 리콜 전 시정보상에 관한 내용을 포함하고 있어 동제도가 소비자보호에 적지 않은 역할을 수행하고 있는 것으로 여겨진다. 다만, 현행 제도는 보상기간을 결함사실이 공개된 날로부터 1년 전 이내라고 하는 단기로 제한하고 있고, 보상을 받을 수 있는 수리비용의 금액을 자동차 제작자가 직접 운영하거나 자동차제작자를 대행하는 자동차종합정비업체에서 해당 결함을 시정하는데 드는 통상적인 비용을 기준으로 산정하는 등 몇 가지 문제점을 안고 있는 것으로 보여진다. 이 논문에서는 현행 자동차 리콜 전 시정보상제도의 문제점들을 지적하고 그 개선방안을 제시한다.

실거래가상환제의 재검토

선정원(Sun Jeong-Won) 행정법이론실무학회 2009 행정법연구 Vol.- No.24

In the 1990s-2000s, pharmaceutical expenditures became a socially important issue because of continuous price inflation. Our reimbursement system consists of reimbursement maximum setting and market price reimbursement. Reimbursement policy must consider balance between national health insurance finance and profits of drug companies or hospitals. Price negotiation power of government is definitely important in maintaining the proper balance. The National Health Insurance Corporation (NHIC) is a public insurer for the public health insurance program in Korea, and The Health Insurance Review Agency (HIRA) is responsible for reviewing medical fees and evaluating whether health care services are medically necessary and delivered to beneficiaries at an appropriate level and cost. However, they have very weak negotiation power under the present 'market price reimbursement system'. A criterion for reimbursement decisions, under this system, is average exchange price, and so, the NHIC must pay the price decided in the market as it is. In addition, drug companies or hospitals report the NHIC how much market price of a drug is, and the reported price, that can be false, becomes, mostly, the market price for reimbursement. It is very hard for The NHIC to know the true exchange price between drug companies and hospitals. Under the present 'market price reimbursement system', pharmaceutical expenditure of government increases fast. Our government has no direct control power of drug price, contrary to lots of developed countries, and can not fix drug price at levels deemed reasonable and affordable to the health care system. Our government can decide only reimbursement maximum. Our reimbursement system, according to principle of economical efficiency, must be reformed for the government to use economic evaluations more positively in drug reimbursement and control drug price for reimbursement directly. First, Drug reimbursement review committee of The Health Insurance Review Agency (HIRA) must be reorganized. Present committee members are mostly pharmacists or physicians, and they are very vulnerable to illegal rebates or illegal lobbying activities by drug companies or hospitals. Second, Reimbursement decision must be cost-effective and consider manufacturing cost of a drug. By price comparison of drugs, government must take proper measures to reduce excessive gap of prices between drugs of the same kind. Third, It must be obligatory on pharmaceutical companies to report manufacturing costs of drugs, and violation of this duty can be connected with sanction instruments such as revocation of patent or drug approval, or exception from drug lists for reimbursement. Fourth, the National Health Insurance Corporation (NHIC) must find typical characteristics of past rebate cases, and if illegal symptoms are showed from companies or hospitals, The NHIC should make powerful administrative investigations, that include frequent unexpected audits or inspections.

Delegation with Asymmetric Reimbursement Systems in an Environmental Conflict

Sung-Hoon Park,GiSeung Kim 한국경제연구학회 2009 Korea and the World Economy Vol.10 No.2

This paper reports on a study that explores how asymmetric reimbursement rules affect effort expended in an environmental conflict. Both lawyers for a citizen group and a polluting firm work on an hourly-fee basis. The citizen group pays a monitoring cost to observe its lawyer?s effort level; whereas, the firm has either in-house legal advice or lawyers on retainer. We examine: (ⅰ) how monitoring cost decreases the citizen group lawyer?s effort level to enable the firm to be the favourite although the firm?s fault exists; (ⅱ) how the reimbursement rule can tilt the contest odds toward the citizen group; and (ⅲ) how the reimbursement rule can increase expected payoff for the citizen group and promote citizen suits. Three findings are as follows: First, the lawyer of the citizen group reduces effort as the monitoring cost of the citizen group increase so that the firm can be the contest favourite with the firm?s fault. Second, the reimbursement rule causes the citizen group to increase its lawyer?s effort level so that it leads the group to be the contest favourite relative to no reimbursement. Third, the reimbursement rule can increase the expected payoff of the citizen group that promotes the citizen suit.

의약품 및 의료기기 생애주기별 국내외 급여 관리제도 비교

윤상헌,박다혜,신서희 건강보험심사평가원 심사평가연구소 2022 연구보고서 Vol.2022 No.0

Background Korean society is aging rapidly and such trend is expected to result in high supply and demand of medicine and medical technology. The phenomenon is likely to lead to increased health expense of the National Health Insurance (NHI) fund, calling for management measures to secure appropriate reimbursement. Against this backdrop, ‘The First Comprehensive Plan of NHI’ has introduced diverse management systems for medicine and medical device, without much success due to conflicts between different programs and purposes. As such, rational and effective adjustment measures are required. Objective This study aimed to systematically and comprehensively review medicine and medical technology management systems on approval, reimbursement, and post management by life cycle. Based on the country comparison and analysis, the results of this study will serve as the baseline data for preemptive system improvement in response to changing health environment. Method This study was largely based on literature review from Korea and abroad as well as consultation of experts in the field. In order to understand current status of reimbursement management systems on medicine and medical technology in Korea and abroad, we analyzed reports of international organizations, papers published in journals, and health-related governmental websites. In addition, interviews took place with professors with expertise and relevant enterprises. Results In this study, the life cycle of a medicine and medical technology consisted of 5 stages: 1) research and development along with regulation and procedure check, 2) approval, 3) manufacture and distribution, 4) NHI coverage listing/reimbursement, and 5) post management. This study consolidated management systems of 7 reference countries (the U.S., the U.K, France, Germany, Italy, Switzerland, Japan) as well as Australia and Canada for full cycle of medicine and medical technology of each country in an organized manner. Conclusion and proposal Korean medicine management system was found to be similar to those of comparison countries with the exceptions of Global Budget and Reference Pricing. There were some confusions coming from use of terminology, as Korea uses differentiated terms such as ‘medical technology’, ‘medical equipment’, and ‘medical device’ depending upon the function, objective, and lifespan of a medicine. Like other reference nations, Korea had systems of phased review, value assessment, and preliminary benefits in place, but it lacked Unique Device Identification (UDI) system for tracking. In regards to medical technology and post management, the level was lower than that of medicine, and reassessment cycle was sparser. The following is suggestions of this study based on such results. First, systematic policy road map and reinforced consumption volume control measures are required. Korea has established and operated medicine management system on par with those of advanced countries, yet systematic inefficiency is an issue as there are hundreds of generic drugs for one medicine. Second, current approval and reimbursement linkage in generic drug pricing system is limited to quality assurance feedback (bioequivalence test, use of registered drug master file), which requires further connection of patient health data of clinical trial. The mechanism should be prepared so that the effective use of approval - reimbursement linkage can be realized. Third, terminology clarification and clean-up is necessary to improve consistency and reduce confusions in the area of approval, reimbursement, and post management. For example in medical technology system, the term ‘medical device’ used for medical supplies covered by NHI could be specified to ‘separately reimbursed medical device’, ‘not separately reimbursed medical device’, and ‘non-benefit medical technology’. Forth, more proactive tracking system is required through revising and reinforcing medical technology and UDI. Fifth, post management of medical device should consider introducing price-volume agreement. Such adoption would require evidence data from suppliers and data transfer system with the review authority, in consideration of both the new products and existing listed products. The objective of reassessment should be clarified as well, whether it should be about management efficiency or cost saving. France’s case could serve as a reference where after a certain period of time from listing, price is adjusted down as the item is categorized as existing group. Sixth, active post management measures should be implemented for high risk medical device, such as adverse drug event reporting system. When the quality is not guaranteed, the item should be subject to elimination from the price list and benefit quality assessment for additional action.

URR 725와 UCP 600 하에서 은행간 대금상환의 적용에 관한 연구

이천수(Cheon-Soo Lee) 한국관세학회 2010 관세학회지 Vol.11 No.1

The purpose of this study is analyze application of the bank-to-bank reimbursement in the documentary credit transactions. Bank-to-bank reimbursement transaction may be ruled under URR 725 or UCP article 13 which was revised by International Chamber of Commerce recently. In order to present practical guidelines for efficient application of the bank-to-bank reimbursement, I studied the following factors under URR 725 and UCP 600 Article 13 ; indication of expiry date in the reimbursement authorization, requirement of certificates of compliance with the terms of a credit in the reimbursement authorization, duplication of a reimbursement authorization, standards for a reimbursement, processing a reimbursement claim, responsibility for reimbursing bank's charges, etc. others. Through this study, it makes possible for concerned parties of documentary credits to establish desirable practices in international payment system in relation to bank-to-bank reimbursement.

임차인의 비용지출 후 임차목적물의 소유자가 변동된 경우 임차인의 비용상환청구권의 법적 근거

강혜림 ( Kang Hye-lim ) 경상대학교 법학연구소 2017 法學硏究 Vol.25 No.2

임차인이 임대차계약의 존속기간 중에 비용을 지출하고 임대인인 소유자가 계약종료에 따라 임차인에게 제213조에 기한 소유물반환을 청구하는 경우, 임차인은 제626조 이외 에 제203조에 따른 비용상환을 청구할 수 있는지에 관한 문제가 있다. 양상환청구권은 그 내용이 거의 동일하기 때문에 물건의 소유권 변동이 없는 경우에는 실질적으로 큰 의 미를 갖지 않는 것으로 보인다. 그러나 대상판결 사안처럼 임차인이 비용을 지출한 후 물건의 소유자가 변동된 경우에는 임차인이 구소유자인 임대인에 대하여 제626조에 기하여 비용상환청구를 할 수 있는지 여부와는 별개로, 신소유자에 대하여 점유자-회복자 관계 규정인 제203조에 의한 비용상환청구를 할 수 있는지 여부가 임차인의 이해와 관련하여 중요한 의미를 가지는 경우가 있다. 대상판결은 제203조는 계약에 의한 점유관계에 관하 여는 원칙적으로 적용될 수 없고, 제203조가 적용되기 위해서는 “비용지출 당시” 점유자는 적법한 점유 권원이 없는 점유자로서 소유자에 대하여 소유물반환의무를 부담하고 있어야 한다고 판시함으로써, 대상판결과 같은 사안에서 임차인은 신소유자에 대하여 제 203조에 따른 비용상환청구를 할 수 없다는 점을 분명히 하고 있다. 그러나 구소유자에 대하여 제626조가 적용되는 경우라고 하여 신소유자에게 제203조가 적용될 수 없는 경우라고 볼 논리적 근거가 없다는 점, 다시 말해 당사자가 상이한 경우에는 당사자별로 적용 규정을 따져보아야 한다는 점, 임차인은 실제로 구소유자에 대한 제626조의 비용상환 청구권 행사가 여의치 않을 때 신소유자에 대한 청구를 고려하게 되는데, 당해 임차인이 대항력을 갖추고 있는 경우와 그렇지 않은 경우를 구분하여, 전자의 경우는 지출비용이 보전될 수 있다고 하는 반면, 후자의 경우는 지출비용이 보전될 수 없다는, 정반대의 결론을 도출할 만한 논리적 근거가 박약한 점, 반면 대항력 없는 임차인에게 임차목적물의 신소유자에 대한 제203조의 비용상환청구권을 인정할 실익은 큰 점, 민법 비용상환 규정 체계상 제203조의 위치, 제203조의 법 문언 등을 고려할 때 대항력 없는 임차인이 임차 목적물을 신소유자에게 반환할 시 제203조에 따른 비용상환을 구할 수 있다고 보는 것이 더 논리적이다. If a lessee has made any expenditures during the lease and after the expiration of the period of the lease a lessor demands the return of the object under the Article 213 of the Korean Civil Act(hereinafter, the "Act"), there is an issue about whether or not the lessee may demand reimbursement for expenditures from the lessor under the Article 203 as well as the Article 626 of the Act. If there is no change in ownership of the object, it seems not to be substantial differences between the case under the Article 203 and the case under the Article 626 of the Act as the contents of the right to demand reimbursement under both Articles are almost same. However, if the owner of the object on the lease has changed during the period of the lease, like in 2001DA64752, it can be critical to the lessee whether or not the lessee may demand reimbursement for expenditures from the new owner under the Article of 203. The Supreme Court has held that the Article 203 cannot be applied to the case where the owner demands the return of the object from the person in possession based on the contract relation and in order for the Article 203 to be applied, when the possessor expenses the costs, the possessor shall not have the right to possess the object. Therefore according to the aforementioned ruling, the lessee cannot demand reimbursement for expenditures from the new owner under the Article 203 because he has made lease contract with the previous owner and expended the costs in the middle of the contract relations. My paper, however, suggests that the aforementioned ruling has resulted from a lack of logical grounds due to the following reasons: (1) even though it is the case where the lessee may demand reimbursement from the previous owner, that is the lessor, under the Article 626, it does not mean that the lessee is banned from demanding the reimbursement from the new owner under the Article 203 of the Act; (2) there is considerable advantages for the lessee without an opposing power if he may demand reimbursement from the new owner under the Article 203 in reality; (3) In consideration of the position of the Article 203 of the reimbursement regulations of the Act and the prescription of the Article 203, the lessee should be qualified to demand reimbursement for the expenditures from the new owner under the Article 203 of the Act.

신용장거래에서 상환은행의 법률적 지위에 관한 연구

김동윤(Dong-Yoon Kim) 한국무역연구원 2013 무역연구 Vol.9 No.3

The purpose of this study is analyze application of the bank-to-bank reimbursement in the documentary credit transactions. Bank-to-bank reimbursement transaction may be ruled under URR725 and UCP600 article 13. A bank which pays out money at the instruction of another bank is entitled to claim reimbursement. Even in a simple money transfer, the issuer of the instruction is under a duty to reimburse the bank instructed by him. When the bank which is instructed to make payment carries out its instruction, a reimbursement right accrues to it. Issues respecting reimbursement through a third party bank arise regularly in letter of credit transactions, for instance, where a negotiating bank is requested to reimburse itself by drawing on the issuing bank's account with the reimbursing bank. But the type of arrangement discussed is not confined to letter of credit transactions. A claiming bank may be authorized to draw on a reimbursing bank in respect of financing packages, such as substantial deals respecting goods, equities or securities. Thought this study, it makes possible for concerned parties of documentary credits to establish desirable practices in international payment system in relation to bank-to-bank reimbursement.

부당발급된 처방전에 의한 의료기관의 약제비반환의무 -서울행정법원 2004.6.1 2003구합20449 사건을 중심으로-

박동진 ( Dong Jin Park ) 한국의료법학회 2004 한국의료법학회지 Vol.12 No.1

The judgment is very significant since it is the first decision of the court addressing that in spite of mistaken prescriptions, it is legally unwarranted that doctors reimburse the National Health Insurance Corporation for medicine cost paid to pharmacies. This meaningful decision makes it clear that the long-standing administrative practice of reimbursement by medical institutions so far is improper. Moreover, the judgment is important on account of its ruling that the Article 52 ① of the National Health Insurance Act applied to this case is not in accordance with the civil law principle, “Restoration of Unjust Enrichment”. In short, the judgment admits that inappropriate customs prevailing in the government's medical administration should be remedied. However, the court just indicates that the present reimbursement system is not reasonable, and does not go further on concrete methods to reform the system. Therefore, it is necessary to review fundamental problems such as who should reimburse for costs incurred by misjudged prescriptions. In the near future, in addition to the confirmation of the court on unjustified precedents, it is essential to explore theoretical and legislative scrutiny with regard to objects and ranges of reimbursement.

병원의 진료비 청구 자체심사 과정과 이의신청 사례

최길림,김원중 한국병원경영학회 2002 병원경영학회지 Vol.7 No.3

The main purpose of this study is to examine the overall procedure of hospital's internal review of health insurance reimbursement, to present the case of protest against reimbursement cut, and hence to provide some information on hospital s management of medical revenue. The object of the case study is 'P' university medical center, possessing 5 different hospitals under its system. Presentation of the case of protest against reimbursement cut has following meanings: Firstly, to the hospitals that already have internal review departments, information on the details of the protest process and results can be exchanged. Secondly, to the Government and National Health Insurance Corporation, useful data are provided for the improvement of the rules and procedures of health insurance reimbursement. Thirdly, to the hospitals without internal review departments, fundamental materials on the internal review process are provided for the effective management of medical revenue.