A patient identified as A was admitted to an oriental medicine clinic after a car accident and received interferential current therapy (ICT). According to the medical bills submitted by the clinic, A underwent physical therapy four times a day, every day, throughout the hospital stay. But the account changed when the insurer checked whether the treatment had actually been provided. A said they had entered the treatment room only once, on the first day of admission. The case pointed to billing that did not match the treatment actually delivered.
Payments for oriental medicine physical therapy under auto insurance have more than doubled in five years. With cases emerging in which clinics billed for more treatment sessions or more body parts than were actually treated, industry officials say tighter review is needed to stop leakage from auto insurance claims for oriental medicine.
Combined payments for oriental medicine physical therapy at the four largest non-life insurers — Samsung Fire & Marine Insurance, Hyundai Marine & Fire Insurance, KB Insurance and DB Insurance — rose 111.3% to 59.8 billion won last year from 28.3 billion won in 2020, according to financial industry sources on the 24th. That is a 2.1-fold increase in just five years, or an average annual growth rate of 16.1%.
Oriental medicine physical therapy refers to treatment based on traditional Korean medicine that uses physical methods such as heat, electricity or mechanical stimulation. Under auto insurance, the category covers ultrasound, shortwave and microwave therapy, along with transcutaneous electrical nerve stimulation (TENS), interferential current therapy (ICT) and cervical and pelvic traction. Spending rose every year, from 28.3 billion won in 2020 to 33.4 billion won in 2021, 43.0 billion won in 2022, 48.2 billion won in 2023 and 57.6 billion won in 2024, before reaching 59.8 billion won last year.
The problem is the emergence of claims suspected of inflating the number of sessions or the number of body parts treated. Under the auto insurance fee schedule, ICT can be billed for inpatients up to twice a day and for up to two body parts per session, for up to 17 days from the date of the accident. Applying both limits allows a clinic to bill four items a day — two body parts multiplied by two sessions.
When one insurer examined the billing records of an oriental medicine clinic, it found cases in which ICT charges were billed repeatedly at the daily maximum for inpatients. Similar cases were found in infrared therapy (IR). In another instance, an insurer found that a clinic had only one piece of the relevant equipment in its treatment room, yet repeatedly billed as if two body parts had been treated in a single session.
Insurers point to the billing and review structure for auto insurance medical costs as the reason such irregular claims are hard to screen out. Clinics submit claims to the Health Insurance Review and Assessment Service (HIRA), which reviews whether they comply with the auto insurance fee schedule. Insurers or mutual aid associations then pay the clinics based on that review. Because billing records alone make it difficult to verify how many times a patient actually received a given treatment, gaps can open up between claims that meet the requirements on paper and the care actually provided.
That has prompted calls for stronger review targeting repeated or irregular claims. "Claims that repeatedly hit the maximum number of sessions, or that depart from typical patterns, need to be examined more closely," an insurance industry official said.
