A court has ruled that it was lawful for South Korea's state health insurer to claw back payments from a hospital that failed to meet the required number of daily monitoring sessions for COVID-19 patients receiving care at home.
The Seoul Administrative Court's Administrative Division 5, presided over by Chief Judge Lee Jeong-won, ruled in August against the plaintiff, identified as A, in a suit filed against the National Health Insurance Service seeking to overturn the clawback, legal sources said on the 18th.
A, who operates a hospital in Seoul's Nowon District, had the facility designated as a COVID-19 home-care management institution from February to April 2022. The hospital received patient management fees from the insurer for managing COVID-19 patients treated at home.
The dispute began when the insurer found that the hospital had violated the criteria for calculating COVID-19 home-care patient management fees. Under the relevant guidelines, the hospital was required to monitor patients in home care twice a day. The hospital, however, treated the twice-daily monitoring requirement as applying to patient management "during" home care, and did not apply the standard on the first and last days of treatment. The insurer deemed this a violation of patient management rules, concluded that about 9.07 million won ($6,300) had been improperly paid, and ordered the money recovered. A then filed an administrative suit.
The court found the insurer's action justified, ruling that the twice-daily monitoring requirement also applies on the first and last days of home care. "The guidelines do divide the periods into the start of home care, the course of home care and its conclusion," the court said, adding that "COVID-19 home care is essentially about health monitoring of confirmed patients, non-face-to-face treatment and response to emergencies." The guidelines set out basic patient management obligations that apply across the entire period of home care, the court said, and cannot be read as exempting the first or last day from the monitoring requirement. The court also noted that exceptions may be recognized where twice-daily monitoring is not practically feasible, but said the materials submitted by A were insufficient to establish such circumstances.
The court further held that recovering the full amount over the failure to meet the monitoring standard did not constitute an abuse or overreach of discretion. Because the recovery of medical fees amounts to the return of unjust enrichment rather than a penalty for a violation, the court ruled, recovering the entire improperly received sum does not breach the principle of proportionality or amount to an abuse of discretion.