Plaintiff (Law Firm LLC, Attorneys Shin Jae-ju, Counsel for the plaintiff-appellant)

National Health Insurance Corporation

October 18, 2018

1. The plaintiff's claim is dismissed.

2. The costs of lawsuit shall be borne by the Plaintiff.

The defendant's notification of the decision to recover medical care benefits on December 29, 2016, and the notification of the decision to recover medical care benefits on January 25, 2017, respectively, shall be revoked.

1. Details of the disposition;

A. The Plaintiff is the head of a hospital operating ○○ Hospital in the Chungcheongnam-nam Budget Group ( Address omitted).

B. On March 14, 2006, ○○○ Hospital was designated as a local emergency medical institution by the Defendant, and around that time, national subsidies paid to local emergency medical institutions by the State, and emergency medical management fees paid by the Defendant for emergency medical service fees.

C. From around August 2011, the Plaintiff was unable to satisfy the requirements for human resources to have at least five exclusive nurses in an emergency room, which are essential requirements for the designation of a local emergency medical institution. In fact, the Plaintiff prepared a list of human resources to be dedicated to the emergency room that at least five nurses work in an emergency room while working for less than five nurses in an emergency room, and had the head of the administrative office of the hospital submit it to the Non-party head of the integrated emergency medical information department at the time of August 201, and maintained the designation of a local emergency medical institution by shotizing false appearance as meeting the requirements for human resources of the above nurses by the same method until August 2016.

D. On November 11, 2016, the Plaintiff and the Nonparty were indicted as the charges of co-principals on the violation of the Subsidy Management Act by deceiving the State and the Plaintiff by means of maintaining the designation of a local emergency medical institution by preparing and submitting a false statement of human resources to take exclusive charge of nursing in the emergency room, such as those on November 11, 2016, and thereby deceiving the State and the Plaintiff, and by receiving the emergency medical service management fees from the Plaintiff, and as the charges of co-principals on the violation of the Subsidy Management Act

E. On August 11, 2017, the above court found the Plaintiff and the Nonparty guilty on the charge of fraud regarding the government subsidy that is the victim and violation of the Subsidy Management Act, and sentenced the Defendant to a suspended sentence of one year and six months, and sentenced the Defendant not guilty on the charges of violating the Act on Fraud and Subsidy Management. Of the above judgment, the Plaintiff and the Nonparty appealed on the guilty portion, and the prosecutor appealed on the non-guilty portion, but the Daejeon District Court, which is the legal ground of the appellate court, dismissed all of the above appeals on February 1, 2018, and only the Plaintiff and the non-party appealed on the above appellate judgment, but the Supreme Court dismissed the Plaintiff and the non-party’s appeal on April 10, 2018.

F. On December 29, 2016, the Defendant issued a disposition to recover 62,638,980 won for emergency medical management fees on the ground that the Plaintiff filed a false claim for emergency medical management fees based on Article 57 of the National Health Insurance Act, and issued a disposition to recover KRW 107,707,590 for the same reason on January 25, 2017 (hereinafter collectively referred to as “instant disposition”).

[Ground for Recognition: Description of Evidence A 2, 3, 5, 6, 15, 16, 17]

2. Summary of the plaintiff's assertion

A. The defendant did not state any fact that is the cause of the disposition in the disposition, while taking the disposition in this case disadvantageous to the plaintiff, and there is procedural error that does not present the ground for the disposition in this case.

B. Even if a hospital designated as a local emergency medical institution fails to meet the designation requirements thereafter, the designation of a local emergency medical institution is not necessarily revoked, and as long as it maintains the designation of a local emergency medical institution, it shall be deemed that it can receive emergency medical management fees. Therefore, even if ○○ Hospital did not meet the designation requirements of a local emergency medical institution, insofar as it received emergency medical management fees under the status of maintaining the designation, the Plaintiff cannot be deemed to have received emergency medical management fees by fraud or other improper means.

3. Relevant statutes;

The entries in the attached statutes are as follows.

4. Whether the disposition of this case is unlawful

A. Whether procedural illegality exists in the procedure for lack of reasons

(1) Relevant legal principles

Article 23(1) of the Administrative Procedures Act provides that an administrative agency shall present the basis and reasons for a disposition. This purport is to exclude the arbitrary decision of the administrative agency and allow the parties to properly cope with the administrative remedy procedure. Accordingly, in full view of the content of the disposition, the relevant statutes, and the overall process leading to the disposition, where it is deemed that there was no particular hindrance in moving into the administrative remedy procedure as a result of sufficiently aware of the existence of the grounds and reasons for the disposition at the time of the disposition, the disposition cannot be deemed unlawful even if the grounds and reasons for the disposition are not specifically stated in the written disposition (see Supreme Court Decision 2016Du4578, Nov. 9, 2016).

(2) Facts of recognition

㈎ 원고는 2016. 8월경부터 수사기관에서 허위의 응급실 전담 간호사 인력표을 제출함으로써 지역응급의료기관 지정을 유지하고, 국고보조금과 응급의료관리료를 편취하였다는 피의사실로 수사를 받게 되었다.

㈏ 피고는 2016. 12. 14. 원고에게, 2011. 4월경부터 2013. 8월경까지 5인 이상의 응급실 간호인력을 충족하지 못한 상태에서 지급된 응급의료관리료를 부당이득금으로 환수할 예정이라는 내용이 기재된 ‘요양급여 환수(전산상계) 예정 통보’를 하였다. 한편, 위 통보문에는 “응급의료기관 평가 사업의 필수영역(시설ㆍ인력ㆍ장비) 중 간호사 인력의 법정기준은 지역응급의료기관(○○○○병원)의 경우 5인 이상 응급실 전담 간호 인력을 충족하여야 하지만 2011년부터 현재까지 5인 이상의 응급실 전담 간호 인력이 근무하지 않으므로 위 응급의료기관 평가의 법정 기준(인력)을 충족하지 못하여 응급환자를 진료하더라도 응급의료관리료를 가산 지급받을 수가 없음”이라는 처분사유가 기재되어 있었다. 이후 피고는 2016. 12. 29. 응급의료관리료 62,638,980원의 환수 처분을 하였다.

㈐ 피고는 2017. 1. 10. 원고에게, 위 ㈏항 기재의 처분사유가 기재된 ‘요양급여비용 환수 예정 통보’를 하였고, 이후 2017. 1. 25. 응급의료관리료 107,707,590원의 환수 처분을 하였다.

㈑ 이 사건 처분의 처분서에는 처분의 근거법령과 처분사유에 관하여 ‘ 국민건강보험법 제57조 ’ 및 ‘허위(부당)청구’만이 기재되어 있다.

[Reasons for Recognition: Evidence as seen earlier, as stated in Evidence Nos. 1 and 6, as a whole, and the purport of the whole pleadings]

(3) Determination

According to the facts acknowledged earlier, it is recognized that the instant disposition written statement contains only the “false claim” with respect to the facts constituting the grounds for the disposition.

However, in light of the following circumstances that can be seen by comprehensively taking into account the details of the above disposition and the above facts, i.e., ① the Plaintiff was under investigation by an investigation agency prior to receiving the notice of scheduled disposition prior to the above disposition and the scheduled disposition, ② the notice of scheduled disposition to be taken, stating specific grounds for the Plaintiff’s recovery of emergency medical care fees paid during the period when the nursing personnel in exclusive charge of emergency room failed to meet the requirements for designation as a local emergency medical institution, ③ in the lawsuit of this case, the Plaintiff asserted the grounds for the above disposition on the premise that the grounds for the disposition of this case did not meet the requirements for designation as a local emergency medical institution. In light of the above circumstances, even though the Plaintiff stated only “the National Health Insurance Act Article 57, false (unfair) claim” as to the grounds and reasons for the disposition of this case, it was sufficiently known that the Plaintiff was sufficiently aware that the disposition of this case was conducted for any reason at the time of the disposition of this case, and there was no particular obstacle to the administrative remedy procedure for the disposition of this case, etc.

(4) The theory of lawsuit

Therefore, the plaintiff's assertion that the disposition of this case should be cancelled due to procedural defects that did not present the reason is without merit.

B. Whether the grounds for disposition are illegal

(1) Details of the relevant statute

㈎ 「응급의료에 관한 법률」(이하 ‘응급의료법’이라 한다) 제31조 제1항 은, 시장ㆍ군수ㆍ구청장은 응급의료에 관한 응급환자의 진료 등의 업무를 수행하게 하기 위하여 종합병원 중에서 지역응급의료기관을 지정할 수 있다고 규정하고 있고, 제2항 은 지역응급의료기관의 지정 기준ㆍ방법ㆍ절차와 업무 등에 필요한 사항은 시ㆍ군ㆍ구의 응급의료 수요와 공급 등을 고려하여 보건복지부령으로 정한다고 규정하고 있다. 그 위임에 따른 「응급의료에 관한 법률 시행규칙」(이하 ‘응급의료법 시행규칙’이라 한다) 제18조 제1항 , [별표 8] 제2호는 인력기준으로 간호사의 경우 ‘5명 이상’이 근무하여야 하는 것으로 규정하고 있다.

㈏ 그리고 응급의료법 제31조의2 는, 응급의료기관은 응급환자를 24시간 진료할 수 있도록 응급의료기관의 지정기준에 따라 시설, 인력 및 장비 등을 유지하여 운영하여야 한다고 규정하고 있고, 제62조 제1항 제1호 는 위 제31조의2 를 위반하여 응급의료기관의 지정기준에 따른 시설ㆍ인력ㆍ장비 등을 유지ㆍ운영하지 아니한 경우를 과태료 처분의 대상이 된다고 규정하고 있다. 한편, 응급의료법 제2조 제5호 에 따르면, 지역응급의료기관도 위 규정에서 말하는 ‘응급의료기관’에 포함된다.

㈐ 한편, 응급의료법 제23조 제1항 은, 응급의료수가(응급의료수가)의 지급기준은 보건복지부장관이 정한다고 규정하고 있는데, 그 위임에 따른 응급의료수가기준(보건복지부고시 제2013-158호, 이하 같다)은, ‘I. 의료기관의 응급의료수가기준, 2. 산정기준’의 항목에서, 응급의료법 제2조 제5호 에 의한 응급의료기관이 응급실에서 응급환자 또는 응급실에 내원한 환자에게 응급처치 및 응급의료를 행한 경우에는 초일에 한하여 [별표 1]의 응급의료수가기준액표에 기재된 “가” 응급의료관리료를 산정한다고 규정하고 있고(가목), 응급환자에게 사용한 약제 및 치료재료에 대한 수가는 국민건강보험법 제45조 의 규정에 의한 건강보험 행위 급여ㆍ비급여 목록표 및 급여 상대가치점수에 의하여 산정한다고 규정하고 있으며(나목), [별표 1] 가목은 지역응급의료기관에 지급되는 응급의료관리료의 상대가치점수를 ‘270.76’으로 규정하고 있다.

㈑ 또한 국민건강보험법 제57조 제1항 은 피고는 속임수나 그 밖의 부당한 방법으로 보험급여를 받은 사람이나 보험급여 비용을 받은 요양기관에 대하여 그 보험급여나 보험급여 비용에 상당하는 금액의 전부 또는 일부를 징수한다고 규정하고 있다.

(2) Whether an emergency medical service management fee can be paid only when it is designated as an emergency medical institution without meeting the manpower standard under the Emergency Medical Service Act and subordinate statutes

In light of the language, structure, and purport of the relevant Acts and subordinate statutes, it is reasonable to deem that the emergency medical service management fees under the Emergency Medical Service Act should be paid for the following reasons. As such, it is reasonable to deem that the emergency medical service management fees ought to meet the human resources standards under the Emergency Medical Service Act and subordinate statutes. Therefore, the payment of emergency medical service fees for emergency medical services performed without meeting the requirements of at least five nurses exclusively in charge of the emergency department, which is the requirements for designation of a local emergency medical institution constitutes “cases where the insurance benefits are

㈎ 응급의료관리법은 국민들이 응급상황에서 신속하고 적절한 응급의료를 받을 수 있도록 응급의료에 관한 국민의 권리와 의무, 국가ㆍ지방자치단체의 책임, 응급의료제공자의 책임과 권리를 정하고 응급의료자원의 효율적 관리에 필요한 사항을 규정함으로써 응급환자의 생명과 건강을 보호하고 국민의료를 적정하게 하기 위하여 제정된 법률인바( 제1조 ), 응급의료법 제31조의2 가 응급의료기관으로 하여금 응급환자를 24시간 진료할 여건을 갖추기 위하여 그 지정 기준에 따라 시설, 인력 및 장비를 유지하여 운영하도록 규정하고, 위와 같은 사항을 과태료 부과 대상으로 규정하여 이를 준수하도록 한 것도 종국적으로는 응급의료의 질을 일정 수준으로 유지하여 국민의 생명과 건강을 보호하기 위한 응급의료법의 입법 취지를 구현하기 위한 것이다.

Therefore, the act of providing emergency medical services in a state where an emergency medical institution fails to meet human resources standards under the Emergency Medical Service Act and the delegation thereof constitutes an act contrary to the legislative intent of the Emergency Medical Service Act, which is intended to protect people’s lives and health by promoting the adequacy of emergency medical services.

㈏ 응급의료법 제23조 제1항 및 그 위임에 따른 응급의료수가기준에 따르면, 응급의료관리료는 ‘응급실에서 응급환자 등에게 응급처치 및 응급의료를 행한 경우’를 기준으로 응급의료관리료를 산정하도록 규정하고 있으므로, 이와 같이 ‘응급처치 및 응급의료 행위’에 대하여 일정한 비율에 따라 지급되는 응급의료관리료는 응급의료기관이 행한 ‘행위’에 대하여 지급되는 것으로 보아야지 이를 단순히 응급의료기관의 지위를 보유하고 있는 것 자체에 대하여 지급되는 것으로 보기는 어렵다.

㈐ 이와 같이 응급의료관리료가 응급처치 및 응급의료행위에 대하여 지급되는 것이라면, 그러한 응급의료행위는 응급의료법령이 정하고 있는 인적ㆍ물적 요건을 갖춘 상태에서 적법하게 이루어질 것을 요한다고 보아야 하고, 만약 이러한 요건을 갖추지 못한 상태에서 이루어진 것이라면 이를 응급의료법령에 따른 응급처치 및 의료행위라고 볼 수 없다.

㈑ 원고는 형사 판결에서, “건강보험심사평가원은 지역응급의료기관 지정 여부를 그 지정서로 확인할 뿐 매 심사시마다 보건복지부에 해당 기관의 응급의료기관 지정 요건 충족 여부를 확인하지 않는다”는 취지의 건강보험심사평가원에 대한 사실조회 결과 등을 기초로 하여, “실제 지역응급의료기관 지정 요건을 충족하고 있는지와 상관없이 위 지정을 유지하고만 있다면 응급의료관리료를 지급받을 수 있다”고 판단한 것을 근거로 들고 있다.

Of course, the fact that a criminal judgment already became final and conclusive in relation to the same facts in an administrative judgment is a serious evidence (see Supreme Court Decision 2010Du12309, Oct. 28, 2010, etc.). However, it cannot be deemed that such effect is recognized even in the interpretation of statutes premised on a criminal judgment.

Even if the Health and Welfare Review and Assessment Service confirms the designation of a local emergency medical institution as the result of fact-finding in the above criminal judgment, and did not verify each time of examination whether the designation of the relevant emergency medical institution satisfies the requirements for designation of the relevant emergency medical institution at each Ministry of Health and Welfare, it is deemed that if the designation of the emergency medical institution is maintained, it did not examine whether the designation of the emergency medical institution satisfies the requirements for designation of the emergency medical institution. Such behavior of the Health and Welfare Review and Assessment Service cannot depend on the requirements for the payment of emergency medical service management fees as prescribed by the Emergency Medical Service Management Act (see Supreme Court Decision 2018Do3551, Apr. 10, 2018). However, in the above criminal judgment, the appeal was dismissed by Supreme Court Decision 201Do351, which did not include the part of the grounds of appeal on the part of innocence as the Defendants who are not public prosecutors. Thus, the part of the judgment that held that “if the aforementioned designation is maintained regardless of whether the requirements for designation of the actual local emergency medical institution are met,

(3) Whether the Plaintiff’s act constitutes “a case where the Plaintiff received the insurance benefit cost by continuous or other unjust means” under Article 57(1) of the National Health Insurance Act

According to the facts acknowledged earlier, the Plaintiff’s claim for emergency medical management fees for emergency medical services performed without meeting the requirements of at least five nurses exclusively in charge of emergency medical services, which was falsely prepared without meeting the requirements for nurse manpower as prescribed by the Emergency Medical Service Act. Thus, according to the aforementioned legal doctrine, the Plaintiff’s claim for emergency medical management fees for emergency medical services performed without meeting the requirements of at least five nurses exclusively in charge of emergency medical services, which is the requirements for the payment of emergency medical management fees, constitutes “speed number or other unfair methods” as prescribed by Article 57(1) of

Therefore, the instant disposition that held that the Defendant’s claim for emergency medical management fees on emergency medical services performed without meeting the designation requirements of the local emergency medical institution constitutes fraudulent and other unlawful means cannot be deemed unlawful.

C. Sub-committee

Ultimately, there is no error as alleged by the plaintiff in the disposition of this case.

5. Conclusion

Therefore, the plaintiff's claim of this case is dismissed as it is without merit, and it is so decided as per Disposition.

(attached Form omitted)

Judges Park Sung-jin (Presiding Judge)