형사소송법 제315조 제3호에 대한 대법원 해석기준과 건강보험심사평가원의 입원적정성 심사의뢰 결과회신자료의 증거활용 검토

한연규 한국형사소송법학회 2019 형사소송 이론과 실무 Vol.11 No.1

A Review of the Supreme Court's interpretation criterion for Article 315-3 of the Criminal Procedure Act and a Study on the Utilization of Evidence of the Response Data on the appropriateness for Hospital admission of Korean Health Insurance Review and Assessment service According to the Insurance Fraud Prevention Special Act enacted in 2016, Korean Health Insurance Review and Assessment Service is obliged to evaluate the appropriateness for hospital admission and inform the investigative agency of the results. Korean Health Insurance Review and Assessment Service has formed and operated a public screening committee consisting of a total of 19 members on Feb. 1, 2017. Recently, the Supreme Court ruled in a row that Korean Health Insurance Review and Assessment Service's answer data on hospitalization does not constitute a document written in a particularly credible situation of Article 315-3 of the Criminal Procedure Act. In the above recent Supreme Court decision, the Supreme Court is based on the Supreme Court Grand Bench Decision(Supreme Court Decision 2015Do2625) as a specific criterion for judgment under Article 3-3 of the Criminal Procedure Act. However, this ruling deals with whether the files confiscated in the NIS election meddling case constitute routine documents drawn up by business needs. The criteria of this judgment in Article 315-3 of the Criminal Procedure Act, which is specifically cited in the above Supreme Court Grand Bench Decision, are for documents that equivalent to routine documents drawn up by business needs of Article 315-2 of the Criminal Procedure Act. Because Korean Health Insurance Review and Assessment Service's answer data on hospitalization is of the nature of documents certified by public authority under Article 315-1 of the Criminal Procedure Act, it is problematic that judging it by the criteria held in the above Supreme Court Grand Bench Decision is problematic. This is not in line with the previous Supreme Court cases in which some documents, (such as a medical certificate drawn up by a military doctor who is a public official, an appraisal request document prepared by the head of National Institute of Scientific Investigation, a market price report on drugs written by the Minister of Health and Welfare, and a market price appraisal document on smuggled goods prepared by customs officials) were recognized as particularly credible documents in which the admissibility of evidence is recognized under article 315 of the Criminal Procedure Act. It is reasonable to regard Korean Health Insurance Review and Assessment Service's reply as being equivalent or similar to a document certified by public authority. 2016. 3. 29. 제정된 보험사기방지특별법에 따라 건강보험심사평가원은 입원 적정성 심사의뢰에 대해 입원적정성을 심사하여 그 결과를 수사기관에 통보하 여야 할 의무가 있다. 이에 건강보험심사평가원은 심사의 공정성, 전문성, 투명 성을 제고하기 위하여 2017. 2. 1. 총 19명으로 구성된 공공심사위원회를 구성 하여 운영해오고 있고, 위 법적 근거에 따라 심평원장은 일반적 직무권한으로서 공공심사위원회에서 의결한 입원적정성 검토결과를 회신하고 있다. 최근 대법원 판결에서는 잇달아 건강보험심사평가원의 입원적정성에 대한 회신자료에 대해서 ‘사무처리 내역을 계속적, 기계적으로 기재한 문서가 아니라 범죄사실의 인정 여부와 관련 있는 어떠한 의견을 제시하는 내용을 담고 있는 문서는 형사소송법 제315조 제3호에서 규정하는 당연히 증거능력이 있는 서류에 해당한다고 볼 수 없다’며 형사소송법 제315조 제3호의 기타 특신문서에 해당되지 않고 나아가 건강보험심사평가원 위원들의 진술에 의하여 성립의 진정 함이 증명되지 않았기 때문에 증거능력이 없다고 판시하였다. 위 최근 대법원 판결에서 형사소송법 제315조 제3호의 구체적인 판단기준의 근거로 제시한 것은 대법원 전원합의체 판결(대법원 2015도2625 판결)이다. 그런데 위 전원합의체 판결은 원세훈 등 국정원 선거개입 댓글사건에서 압수파일이 업무상 통상문서에 해당되는지 여부를 다룬 것으로서 위 판결에서 구체적으로 들고 있는 형사소송법 제315조 제3호의 판단기준은 같은 조 제2호의 업무상 통상문서에 준하는 문서에 대한 것이다. 반면, 건강보험심사평가원의 입원적정 성에 대한 회신자료는 같은 조 제1호의 공권적 증명문서로서의 성질을 가지는 것으로서 엄연히 업무상 통상문서와는 성질이 다르기 때문에 다른 판단기준으로 살펴봐야 한다. 형사소송법 제315조 제3호의 기타 특신문서 여부를 판단할 때에는, 공권적 증명문서(제1호)와 유사한 서류에 대해서는 공무원이 작성한 직무상 증명사항 인지 여부 등을 기준으로 검토하여야 하고, 업무상 통상문서(2호)와 유사한 서류에 대해서는 작성자의 주관이 개입될 여지가 적은 기계적이고 반복적인 사무 처리 내역 사항인지 여부 등을 기준으로 구분하여 검토하는 것이 상당하다. 그럼에도 불구하고 심평원 회신자료의 특신문서성을 부정한 최근 대법원 판결(대 법원 2017도12671호 판결)은 형사소송법 제315조 제3호에 대한 전원합의체 판결(대법원 2015도2625 판결)에서 제시한 업무상 통상문서 여부에 대한 구체적인 판단기준을 공권적 증명문서의 성질을 가지는 심평원 회신자료에 그대로 사용하면서 판단의 오류가 발생하였다고 본다. 이는 기존 대법원 판례가 공무원인 군의관 작성의 진단서, 국립과학수사연구소장 작성의 감정의뢰 회보서, 보건 복지부장관의 마약에 관한 시가보고서, 세관공무원의 범칙물자에 대한 시가감 정서 등을 형사소송법 제315조 상의 당연히 증거능력이 인정되는 특신문서로 인정해온 입장과도 맞지 않다. 심평원 회신자료는 공무원이 자신의 직무 범위 안에서 전문성을 가지고 공적으로 증명하고 있는 사항에 대한 공권적 증명문서에 해당하거나 그와 유사한 것이라고 봄이 상당하다. 한편, 그 증거능력이 인정된다 하더라도 건강보험심사평가원 회신자료의 내용이 충실하지 못한 부분에 대해서는 충분히 비판이 가능하고 개선이 필요하 ...

건강보험심사평가원을 활용한 실손의료보험의 보험금 관리방안

김대환 ( Daehwan Kim ),오영수 ( Young-soo Oh ) 한국리스크관리학회 2016 리스크 管理硏究 Vol.27 No.1

국민건강보험의 보장률이 낮은 상황에서 실손의료보험은 국민의 의료접근성과 건강 권을 위한 중요한 사적안전망으로 자리매김하고 있다. 하지만 우리나라의 실손의료보험은 보장은 하되 보험금을 심사할 수 없는 기형적인 형태로 운영되면서 실손의료보험의 보험료와 해지율 증가로 보험 본연의 기능을 수행하지 못하고 있다. 이에 본 연구에서는 실손의료보험이 의료비 보장을 위한 사적안전망으로서 본연의 기능이 발휘되기 위한 다 양한 진료비 관리방안을 모색하고 우리나라 실정에 부합하는 대안을 제시하였다. 진료비 심사의 전문성, 일관성, 그리고 비용효율성을 고려할 때 건강보험심사평가원을 활용하는 방안이 현실적인 대안이며 두 가지 접근이 가능하다. 첫째, 대부분의 비급여의료를 급여화하되 비용효과성 및 중요성 등을 바탕으로 급여율을 다양화하고 국민건강보험이 보장하지 않는 의료비를 실손의료보험이 보장하는 방안이 적절하다. 둘째, 비급여의료를 급여화하기 위해서는 상당한 시일이 소요될 수 있으므로 자동차 보험 진료비심사를 건강보험심사평가원에 위탁하는 시스템에 실손의료보험의 진료비심사를 통합하는 방안을 우선 추진할 수 있다. 하지만 건강보험심사평가원에 위탁하는 방안은 실손의료보험의 진료비 심사라는 협의의 목적달성을 위한 것으로 비급여의료로 인해 급증하는 의료비 문제를 해결하고 보건의료체계의 지속가능성을 담보하기 위해서는 비급여의료의 급여화로 발전시켜 나가야 할 것이다. The fee-for-service (FFS) health insurance has played an important role for covering the medical costs as the coverage of public health insurance is low. However, there is no proper way for screening the claims of FFS health insurance and this has resulted into a higher loss ratio and premium. This study diagnoses various ways for screening the claims and suggests two desirable screening ways. Based on cost-effectiveness and consistency of screening the claims, it is better to utilize the Health Insurance Review & Assessment Service (HIRAS). There are two ways of utilizing this. First, the FFS health insurance covers all out-of-pocket costs after transferring all non-benefited medicines of the public health insurance into benefited medicines. Second, HIRAS is currently screening medical claims for auto insurance, operated by the private insurance company. It is considerable that HIRAS takes charge of screening the claims from FFS health insurance. However, the second approach is to achieve a narrower interpretation of FFS medical costs. That is why it is necessary to move into the direction to benefited medicines in order to solve the issue of rapidly increasing medical costs due to non-benefited medicines, and to secure sustainability of the National health care system.

Dilemmas Within the Korean Health Insurance System

박동휘,장민철 대한예방의학회 2020 Journal of Preventive Medicine and Public Health Vol.53 No.4

The health insurance system in Korea is well-established and provides benefits for the entire national population. In Korea, when patients are treated at a hospital, the hospital receives a partial payment for the treatment from the patient, and the remaining amount is provided by the health insurance service. The Health Insurance Review and Assessment Service (HIRA) assesses whether the treatment was appropriate. If HIRA deems the treatment appropriate, the doctor can receive payment from the health insurance service. However, this system has several drawbacks. In this study, we aimed to provide examples of the problems that can occur in relation to HIRA assessments in Korea through actual clinical cases.

Dilemmas Within the Korean Health Insurance System

Park, Donghwi,Chang, Min Cheol The Korean Society for Preventive Medicine 2020 Journal of Preventive Medicine and Public Health Vol.53 No.4

The health insurance system in Korea is well-established and provides benefits for the entire national population. In Korea, when patients are treated at a hospital, the hospital receives a partial payment for the treatment from the patient, and the remaining amount is provided by the health insurance service. The Health Insurance Review and Assessment Service (HIRA) assesses whether the treatment was appropriate. If HIRA deems the treatment appropriate, the doctor can receive payment from the health insurance service. However, this system has several drawbacks. In this study, we aimed to provide examples of the problems that can occur in relation to HIRA assessments in Korea through actual clinical cases.

건강보험심사평가원 자료를 활용한 보건사회약학연구

최남경 한국보건사회약료경영학회 2015 한국보건사회약료경영학회지 Vol.4 No.1

BACKGROUNDS Health insurance administrative databases are important sources of information in finding health-related evidence. The objective of this study was to introduce the Korean Health Insurance Review and Assessment Service (HIRA) claims database to perform public health and social pharmacy studies. METHODS This article introduces the contents and characteristics of the HIRA data, describes the data acquisition procedures, provides examples of studies carried out using the data, and discusses several aspects that requires attention in those studies. RESULTS The HIRA claims database contains information on all claims including patients’ diagnoses, treatments, procedures, and prescription drugs for approximately 50 million Koreans. This database can be used for the following analyses: estimation of incidence or prevalence for a variety of specific disease, description of the utilization of health care resources and services, and verification of hypotheses about the health outcomes. This database has advantages including low cost, ease of patient follow-up over long time periods, and absence of reporting bias. There are several limitations of using this database including uncertain or low validity of disease diagnoses, potential discrepancies between physician’s prescriptions and patient’s actual medication intake, and lack of laboratory results and health-related behavioral information. CONCLUSION The HIRA data provide tremendous opportunities to perform large-scale quantitative analyses in the fields of public health and social pharmacy. A better understanding of prescribing practice, health policy, and data structures allows the researchers to use the claim database appropriately.

급성기 뇌졸중 적정성 평가 결과의 분석

최은영,옥민수,이현정,조민우,이상일 한국보건의료기술평가학회 2017 보건의료기술평가 Vol.5 No.1

Objectives: The Health Insurance Review and Assessment Service (HIRA) has been implement- ing quality assessment program to improve the quality of care for acute stroke patients. The purpose of this study was to evaluating the performance of the program. Methods: We compared the assess- ment results of the year 2008 or 2009 with those of the year 2014. Also we analyzed the assessment results by hospital size and number of case for hospital using 2014 dataset. The total number of indi- cators used in this analysis is thirteen including two structure indicators and eleven process indica- tors. Results: The performance of the quality assessment program was generally improved from the year 2008/2009 to 2014. We found that small and medium sized hospital showed relatively low level of quality. There were substantial variations in the level of achievement among indicators. Con- clusion: To improve the overall quality of stroke care, we have to pay more attentions to small and medium sized hospitals. HIRA need to expand the quality assessment program for acute stroke pa- tients in order to cover small and medium sized hospitals. Furthermore, it is necessary to develop quality improvement program to support low performance hospitals.

실손의료보험 청구체계 개선방안에 관한 연구 - 보험업법 개정안을 중심으로 -

전한덕 한국소비자원 2020 消費者問題硏究 Vol.51 No.2

The fundamental reason why insurance consumers do not claim insurance money even after purchasing private health insurance is because the claim process is too difficult and complicated. Therefore, if the claim process for private health insurance would be simplified, the claim for private health insurance will be actively made. Despite much effort, the main reason for the failure to simplify the claims process for private health insurance was the conflict with existing Medical Law and strong opposition from stakeholders, including the medical community. However the issue of simplifying the claim process for private health insurance needs to be considered with the interest of insurance consumers. If the claims process for private health insurance would be simplified, the claims ratio will increase, which could greatly contribute to reducing the burden of medical expenses for insurance consumers. It is only natural for insurance consumers to pay a legitimate premium and receive a legitimate insurance payment from insurance companies in the event of an insurance accident. It is undesirable for these rights to be obstructed or virtually violated by the complexity of the claims process, given the social role and function of insurance. In this thesis, I will deal with the current status of private health insurance and the simplification of insurance claim procedures. In particular, I will analyze the main contents of amendments to the Insurance Business Law, which was recently submitted to the 21th National Assembly, and present problems and improvement measures. 보험소비자들이 실손의료보험을 가입하고도 보험금을 청구하지 않는 근본적인 이유는 청구절차가 너무까다롭고 복잡하게 되어있기 때문이다. 따라서 실손의료보험 청구절차를 간소화한다면 실손의료보험청구가 활발하게 이루어질 것으로 예상된다. 그 결과 보험가입자들의 보험금 미청구 건수가 줄어들게되고, 의료비 부담이 상당부분 경감될 것이며, 나아가 실손의료보험이 공보험의 보충적 역할을 충실하게수행하게 될 것이다. 그 동안 많은 노력이 있었음에도 불구하고 실손의료보험 청구절차 간소화가 성사되지못하는 주된 이유로는 기존 의료법과의 상충 문제 및 의료계 등 이해당사자들의 강력한 반대가 있었기때문이다. 그러나 실손의료보험 청구절차 간소화 문제는 의료계와 보험회사라는 거대 이익집단의이해관계 관점에서 바라보는 것은 바람직하지 않고, 무엇보다 보험소비자의 이익을 우선하여 검토해야한다. 보험소비자가 보험료를 지불하고, 보험사고 발생시 보험회사로부터 정당한 보험금을 지급받는 것은보험의 원리를 놓고 봤을 때 너무나 당연한 권리다. 이러한 권리가 그 청구절차의 복잡성으로 방해받거나사실상 침해되는 것은 보험의 사회적 역할과 기능을 놓고 봤을 때 바람직하지 않다. 본 논문에서는실손의료보험 현황과 보험금 청구절차 간소화 방안을 다루고 있다. 특히 최근 21대 국회에서 발의된실손의료보험 보험금 청구 절차 간소화 방안을 담은 보험업법 일부개정법률안의 주요 내용을 분석하고문제점과 개선방안을 제시한다.

최근 10년간 국내 녹내장 진단 현황 변화 : 건강보험심사평가원 자료 2010-2019

최지호(Ji Ho Choi),이태은(Tae Eun Lee) 대한안과학회 2021 대한안과학회지 Vol.62 No.9

목적: 건강보험심사평가원 자료를 이용하여 최근 10년간 국내 녹내장 진단 현황과 변화 추이를 알아보고자 하였다. 대상과 방법: 보건의료빅데이터개방시스템에 공개된 의료통계정보의 질병 세분류 통계에서 2010년부터 2019년까지 녹내장 진단코드로 요양급여비용이 청구된 건강보험 환자 수를 수집하였다. 각각의 진단코드에 대해 연도별, 연령대별, 성별로 나누어 자료를 수집한 후 연령별 단위 인구 10만 명 당 녹내장 진료 현황의 변화를 분석하였다. 통계는 접합점 회귀분석을 이용하여 각각의 세부진단코드에 대해 증감 추세 및 연구 기간 동안 추세 변화 여부를 확인하였다. 결과: 2010년 대비 2019년 녹내장 진단코드로 진료를 본 건강보험 환자 수는 120.3% 증가하였으며, 의료보장인구 10만 명 당 109.5% 증가하였다. 이러한 증가 추세는 2015년 기준으로 그 상승세가 둔화되었다. 각 세부진단코드별로는 녹내장 의심, 원발성 개방우각녹내장, 원발성 폐쇄우각녹내장은 증가 추세를 보인 반면 눈외상에 따른 이차녹내장과 약물에 의한 이차녹내장은 뚜렷한 감소세를 보였다. 눈염증에 따른 이차녹내장은 통계적으로 유의한 추세 변화를 보이지 않았으며 기타 눈장애에 따른 이차녹내장과 상세불명의 녹내장은 증가 추세를 보였다. 기타 녹내장은 2010년부터 2012년까지 감소하다 다시 증가하였다. 결론: 2010년부터 2019년까지 전체 건강보험 환자 중 녹내장으로 진료받은 환자의 수는 급격히 증가하였다. 전체적인 증가 추세에도 불구하고 눈외상과 약물에 의한 이차녹내장은 뚜렷한 감소 추세를 보였다. Purpose: We determined the current status of glaucoma diagnoses in Korea and trends in the change over the past 10 years using data from the Health Insurance Review and Assessment Service. Methods: The glaucoma diagnostic code was collected from the disease subclass statistics of the medical statistical information disclosed in the Healthcare Bigdata open system, and the number of health insurance patients who were billed for medical care benefit costs from 2010 to 2019 with the glaucoma diagnosis code was collected. Data were collected for each diagnostic code by dividing it by year, age group, and gender, and then changes in the current status of glaucoma diagnosis per 100,000 people were analyzed by age group. A joinpoint regression analysis was used to determine the increasing and decreasing trends for each diagnostic code and whether the trend changed during the study period. Results: The number of health insurance patients who received treatment with the glaucoma diagnostic code in 2019 compared to 2010 increased by 120.3% and 109.5% per 100,000 people covered by medical care. This increasing trend has slowed as of 2015. Suspected glaucoma, primary open-angle glaucoma, and primary angle-closure glaucoma showed an increasing trend, while glaucoma secondary to eye trauma and glaucoma secondary to drugs declined markedly. No significant trend in glaucoma secondary to eye inflammation was detected, and glaucoma secondary to other eye disorders and unspecified glaucoma tended to increase. Other glaucoma diagnoses decreased from 2010 to 2012 and then increased. Conclusions: The number of patients who underwent glaucoma treatment among all health insurance patients increased significantly from 2010 to 2019. Despite the overall increasing trend, eye trauma and drug-induced secondary glaucoma have markedly decreased.

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.

신세포암에 사용되는 전신 항암요법의 요양급여기준에 관한 고찰

김정연,박은지,배민경,윤정현 한국임상약학회 2011 한국임상약학회지 Vol.21 No.4

Purpose: The purpose of this study is to evaluate current criteria for insurance coverage by Health Insurance Review & Assessment Service (HIRA) on the systemic therapy used in the treatment of advanced or metastatic renal cell carcinoma (RCC), by reviewing all available clinical evidences including a variety of clinical practice guidelines. Methods:We searched clinical databases and collected data from published phase 1 through 3 randomized clinical trials on all systemic therapies used in RCC, including novel targeted therapies. Additionally, current clinical practice guidelines on the management of kidney cancer or RCC were reviewed. Based on the collected data we evaluated the appropriateness of the HIRA criteria for insurance coverage on the systemic therapy of RCC whether they are evidence-based and up to date. Results: On the basis of the collected data we concluded that there was a need for a revision in HIRA criteria for systemic therapy of RCC. Despite recent emerging therapeutic advances and changes in therapeutic strategies of management of RCC, some of anticancer regimens were inappropriately listed even though they were not proven to provide efficacy or safety superior to those of other therapies. We thus proposed an updated recommendation based on current clinical evidences. Conclusion: Systemic therapy of RCC is being rapidly changed with the advancement of understanding of the molecular biology of cancer. Consequently newly developed targeted therapies are becoming the standard therapy in the management of medically or surgically unresectable advanced or metastatic RCC. To provide effective and safe therapy to patients with RCC, the criteria for insurance coverage should be made carefully taking into consideration of most up-todate and high-quality clinical evidences, and should be continuously reviewed so as to reflect evidence-based clinical practice.