• The Korean Society of Law and Medicine
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• v.13 no.1
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• pp.41-69
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• 2012

First introduced in 1977, Korean health care system reached to national coverage in short period of time never seen before in any other countries, and rated as successful system protecting the health of the public at relatively low price. However, despite those positive evaluations, some of fraudulent medical organizations or pharmacies are hindering the sound development of the national health care system with meticulous false billing exaggerating the number of patients or the days of their treatment. To prevent aforementioned nursing home fraud and false billing, the misconduct should be punished as subject to the criminal law and severally punished for fines and payments which far exceed the expected amount of illicit gains as it is basically violation of criminal fraud, other than the forced return of illicit gains based on civil laws. Furthermore, the Health Insurance Review and Assessment Service should strengthen and complement the fraud investigators, the review process, and the professional training to raise the detection rates. It might also want to review ways to implement whistleblower rewarding system and rewards for evidences of healthcare fraud to overcome the limits of external review.

• The Korean Society of Law and Medicine
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• v.14 no.2
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• pp.11-41
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• 2013

Article 347 of criminal law provides the act of deceiving another, thereby taking property or obtaining pecuniary advantage from another. On the other hand, the concepts of fraud and abuse are confused upon interpretation since the definition in National Healthcare Insurance Law is unclear, and it affects closely to the administrative measures such as surcharge levy by the period of inspection, therefore, the disputes continue in the forms of formal objection, administrative ruling and administrative litigation. This study aims to look over the legal problems on application of criminal fraud toward the abuse of 'Paid Medical Expenses(Article 57, Sections 1 and 4 of the National Health Insurance Act)'. The main issues are concept of abuse(Article 57, Sections 1 and 4 of the National Health Insurance Act), the problems of Directions of Health-Welfare Ministry on aspect of 'Nullum crimen sine lege' Principles, the proper sentenc-ing guidelines of fraud.

• KSII Transactions on Internet and Information Systems (TIIS)
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• v.16 no.3
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• pp.1006-1027
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• 2022

In the crowdfunding market, various crowdfunding platforms can offer founders the possibilities to collect funding and launch someone's next campaign, project or events. Especially, healthcare crowdfunding is a field that is growing rapidly on health-related problems based on online platforms. One of the largest platforms, GoFundMe, has raised US$ 5 billion since 2010. Unfortunately, while providing crucial help to care for many people, it is also increasing risk of fraud. Using the largest platform of crowdfunding market, GoFundMe, we conduct an exhaustive search of detection on fraud from October 2016 to September 2019. Data sets are based on 6 main types of medical focused crowdfunding campaigns or events, such as cancer, in vitro fertilization (IVF), leukemia, health insurance, lymphoma and, surgery type. This study evaluated a detect of fraud process to identify fraud from non-fraud healthcare crowdfunding campaigns using various machine learning technics.

• 한국IT서비스학회:학술대회논문집
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• 2009.05a
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• pp.357-360
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• 2009

본 연구는 데이터마이닝 기법을 이용하여 건강보험청구료에 있어서 이상정도가 심한 요양기관을 탐지하고, 실제 의료영역에 적용하기 위한 시스템 개발을 목적으로 한다. 현재 건강보험 심사평가원의 이상탐지시스템은 평가대상이 되는 항목을 개별적으로 평가하고, 탐지된 기관의 선정 이유에 대한 근거제시가 부족한 단점을 가지고 있다. 따라서 본 연구에서는 항목을 종합적으로 평가할 수 있는 정량적 지표를 설계하고, 항목들의 상대적 중요도를 파악할 수 있도록 항목들에 대한 가중치 부여한다. 또한 지표에서 얻어진 값으로 등급을 구분하고, 의사결정나무기법(decision tree)를 이용하여 해석력을 높이는 방법을 제시한다.

• The Journal of the Convergence on Culture Technology
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• v.9 no.6
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• pp.801-805
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• 2023

In Korea, the population is continuously decreasing due to the decrease in fertility rates. Military troops are continuously decreasing, but soldiers' suicide, mental health care and medicine prescriptions, and inadequate decisions are increasing. In other words, the mental health of the intestines is getting worse. The mental health of the soldiers is a personal problem, but it can also have a big impact on the troops. This is because accidents such as suicide, divorce, and military leave lead to the restriction of the combat power and the deterioration of fraud. Currently, domestic and foreign academics are studying mental health care plans using wearable devices. The Korean military can also use this to objectively measure the mental health of soldiers and use the accumulated big data to predict and measure various situations. In this study, this study suggests mental health care measures for military soldiers using wearable devices, and further research will be conducted smoothly to improve the mental health of our soldiers.

• Health Policy and Management
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• v.19 no.3
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• pp.109-124
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• 2009

Background: This study aimed to examine whether cases of punishing false claimants threat general physicians to check their medical cost claims with care to avoid being suspected, and identify empirically general deterrence effects of the on-site investigation system in the Korean National Health Insurance. Methods: 800 clinics were selected among a total of 15,443 clinics that had no experience of on-site investigation until June 2007 using a stratified proportional systematic sampling method. We conducted logistic multiple regression to examine the association between factors related to provider's perception of on-site investigation and high level of perceived deterrence referring to fear of punishment after adjusting provider's service experiences and general characteristics. Results: The probability of high perceived deterrence was higher 1.7 times (CI: 1.13-2.56), 2.73 times (CI: 1.68-4.45) each among clinics exchanging the information once or more per year or once or more for 2-3 months than among clinics no exchanging the information about on-site investigation. Also, the probability of high perceived deterrence was higher 2.27 times (CI: 1.28-4.45) among clinics that knows more than 3 health care institutions having experienced an on-site investigation than among clinics knowing no case. Conclusion: A clinic knowing more punishment cases by onsite investigation and exchanging more frequently information about on-site investigation is likely to present high perceived deterrence. This result will provide important information to enlarge preventive effects of on-site investigation on fraud and abuse claims.

• The Journal of Korea Institute of Information, Electronics, and Communication Technology
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• v.11 no.6
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• pp.718-723
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• 2018

In a positive Internet of Medical Things (IoMT) environment, by combining the latest computer network technology with IoT technology, remote health care such as health care and monitoring is improved through the provision of quality medical information services. In this paper, we identified and compared the platforms applied with blockchain and presented the results of developing the product distribution de-centralized DApp. In the process, we developed a distribution platform that can use blockchain technology to identify product fraud, manage data, manage customers' information, prevent forgery, track transaction history, and facilitate product transactions.

• The Korean Society of Law and Medicine
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• v.21 no.1
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• pp.33-67
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• 2020

The hospitals that are owned by non-medical personnel result when non-medical personnel with resources conspire with newly graduated medical doctors who cannot afford the enormous amount of capital required at the beginning of the establishment of a medical institution. Such hospitals, though they may have met the external requirements as medical institutions, disrupt the medical market as it should be centered by medical personnels, In addition, such hospitals are causing a huge social problem as it is illegally receiving and reducing various benefits such as medical care benefits and subsidies from the government, resulting in a significant financial leak in the national health insurance. The illegality of the opening of a non-medical personnel hospital is so high that it nullifies the contractual arrangement for the establishment, imposes criminal penalties on all persons involved in the establishment under the Korean Medical Law, and imposes administrative sanctions on medical personnel. In case the hospital was aware of the illegality of its opening, but had applied to receive medical care benefits from the National Health Insurance Act and the Medical Care Act, such actions will result in the return of the benefits under the National Health Insurance Act and the Medical Care Assistance Act, subject to the penalty for the crime of fraud, and aggravated punishment for specific economic crimes based on the amount of gain, as well as civil liability for torts. In this study, we will examine the current status of the regulations on the non-medical personnel hospital and present the basis for future legislative directions by looking at the legal regulations and the attitude of the precedents.

• Journal of Korea Society of Digital Industry and Information Management
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• v.19 no.1
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• pp.77-89
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• 2023

The purpose of this study is to empirically confirm what is an important variable of organizational change by intelligent technology acceptance and whether is a difference in important variables in the organization level of acceptance of intelligent technology. Recently, business models using intelligent technologies such as chat-bots, self-driving cars, credit-prevention fraud, face recognition, and health-care are emerging. External situation factors such as artificial intelligence, big data, COVID-19, and the ESG management are changing the direction of a company's management strategy. This research method established a structural equation model. As a result of the analysis, we found that the leadership, organizational culture, and organizational cooperation variables had a positive effect on human resource development variables. Human resource development found a positive effect on the performance of intelligent technology. In addition, we found the independent variables of leadership, organizational culture, and organizational cooperation had partial mediating effects on the performance of intelligent technology. Each group of levels of intelligent technology found performance differences. The organizational culture variables appeared as important variables in all groups. On the other hand, the leadership variable appeared as an important variable in the middle and lower groups of intelligent technology. The theoretical background of this study is that the business theory was updated through artificial intelligence and intelligent technology theory. As a practical implication, the organization adopting intelligent technology is necessary to prepare a systematic plan for organizational culture change.