Overbilling of medical treatment expenses under the Health Insurance Act and other applicable laws
株式会社クニカネクスト (the Company's unconsolidated subsidiary)
4 treatment facilities in Kawagoe, Saitama Prefecture; Fuchu, Tokyo; Fushimi Ward, Kyoto; and Moriguchi, Osaka Prefecture. Home-visit medical massage services. Otsu, Shiga Prefecture, was also included in the investigation, but no overbilling was identified there.
① Reconciliation of treatment records with medical treatment expense reimbursement applications was not conducted adequately; ② understanding of the calculation rules for the add-on for corrective manual therapy and the number of treatment sites was insufficient; ③ the management review process before claims were submitted did not function adequately; and ④ support for visually impaired practitioners in reviewing records and claims was insufficient.
The overbilled amount, which is also the repayment amount, totaled ¥4,246,360. The impact on consolidated results is minor. The specific accounting impact and accounting classification are not disclosed. The amount may increase or decrease depending on the timing of resubmitted claims.
The impact on consolidated results is minor. The figures following any revision to the earnings forecast are not disclosed.
Related procedures
Reporting the matter to the Regional Bureau of Health and Welfare, cancellation of medical treatment expense claims, and procedures to repay insurers and service users
指導監査課, Kanto-Shinetsu Regional Bureau of Health and Welfare; Tokyo Office, Kanto-Shinetsu Regional Bureau of Health and Welfare; Kyoto Office, Kinki Regional Bureau of Health and Welfare; and 指導監査課, Kinki Regional Bureau of Health and Welfare
Company response
An internal investigation was conducted. A third-party committee, special investigation committee, and external experts were not disclosed.
Introduction of a three-stage checking system (strengthening the review process before claims are submitted) / revision of treatment record forms and transition to new forms / preparation of a medical treatment expense claims manual, with reviews based on the PDCA cycle / internal audits (annual audits) / regular practitioner training / improvements to the claims system (customization or replacement)
The Company will carry out procedures to repay insurers and service users and implement appropriate measures to prevent recurrence.
If any matter arises that requires disclosure under the timely disclosure rules, it will be announced promptly.
| Item | Details |
|---|---|
| Event name | Overbilling of medical treatment expenses under the Health Insurance Act and other applicable laws |
| Date of occurrence | January 2021 to February 2026 (period during which overbilling occurred) |
| Date recognized / date notice received | Around 20 January 2026 (when suspected overbilling in Kawagoe, Saitama Prefecture, was identified) |
| Subject Entity | 株式会社クニカネクスト (the Company's unconsolidated subsidiary) |
| Target Locations / Products | 4 treatment facilities in Kawagoe, Saitama Prefecture; Fuchu, Tokyo; Fushimi Ward, Kyoto; and Moriguchi, Osaka Prefecture. Home-visit medical massage services. Otsu, Shiga Prefecture, was also included in the investigation, but no overbilling was identified there. |
| Cause | ① Reconciliation of treatment records with medical treatment expense reimbursement applications was not conducted adequately; ② understanding of the calculation rules for the add-on for corrective manual therapy and the number of treatment sites was insufficient; ③ the management review process before claims were submitted did not function adequately; and ④ support for visually impaired practitioners in reviewing records and claims was insufficient. |
| Amount of Impact on Business Performance | The overbilled amount, which is also the repayment amount, totaled ¥4,246,360. The impact on consolidated results is minor. The specific accounting impact and accounting classification are not disclosed. The amount may increase or decrease depending on the timing of resubmitted claims. |
| Impact on Earnings Forecast | The impact on consolidated results is minor. The figures following any revision to the earnings forecast are not disclosed. |
| Type of litigation or proceeding | Reporting the matter to the Regional Bureau of Health and Welfare, cancellation of medical treatment expense claims, and procedures to repay insurers and service users |
| Court or authority | 指導監査課, Kanto-Shinetsu Regional Bureau of Health and Welfare; Tokyo Office, Kanto-Shinetsu Regional Bureau of Health and Welfare; Kyoto Office, Kinki Regional Bureau of Health and Welfare; and 指導監査課, Kinki Regional Bureau of Health and Welfare |
| Investigation structure | An internal investigation was conducted. A third-party committee, special investigation committee, and external experts were not disclosed. |
| Measures to prevent recurrence | Introduction of a three-stage checking system (strengthening the review process before claims are submitted) / revision of treatment record forms and transition to new forms / preparation of a medical treatment expense claims manual, with reviews based on the PDCA cycle / internal audits (annual audits) / regular practitioner training / improvements to the claims system (customization or replacement) |
| Outlook | The Company will carry out procedures to repay insurers and service users and implement appropriate measures to prevent recurrence. |
| Planned follow-up disclosure | If any matter arises that requires disclosure under the timely disclosure rules, it will be announced promptly. |
Items this document does not state (11)
These are items the company does not state in this document. We do not leave them blank, nor fill them in from other sources or by inference.
The reasons the company gives
The company's own explanation, not something inferred from the numbers.This resulted from inadequate reconciliation of treatment records with medical treatment expense reimbursement applications, insufficient understanding of the calculation rules, an inadequate management review process before claims were submitted, and insufficient support for visually impaired practitioners in reviewing records and claims.