• Journal of the Korea Convergence Society
• /
• v.13 no.5
• /
• pp.77-84
• /
• 2022

The purpose of this study is to provide basic data necessary for preparing a sustainable health insurance system in the future by analyzing the difference in the results of claims according to the claims status of health insurance of dental medical institutions and the level of health insurance knowledge. In this study, a self-written online questionnaire was conducted for dental medical institutions 209 workers from March to May 2019. As a result of the study, The demand for professional manpower according to claim satisfaction was statistically significant in the qualification requirements (p<.05). Therefore, the necessity of professional workers for dental health insurance claims was confirmed and policies for this should be prepared.

• Journal of Convergence for Information Technology
• /
• v.9 no.9
• /
• pp.195-200
• /
• 2019

The purpose of this study is to analyze the characteristics of National Health Insurance claim data and to construct a pilot medical episode data considering it. In this study, the trends of respiratory disease (ICD10: J00-J99) cardiovascular disease (ICD10: I00-I99) from the day of onset of treatment to re-admission after admission were confirmed in Seoul, and the largest decrease was observed when the no-treatment period was 0 day. The data reduction rate when the no-treatment period is 0 day is judged to be due to the monthly separation claim of the health insurance claim data. Also, the result that there is a tendency of monthly separation request according to the type of medical treatment. Through this study, we constructed epidemic data for the pilot medical treatment considering the characteristics of the claim data of health insurance, and based on this, it can be used as a data processing method for calculating basic epidemiological information.

• Journal of Digital Convergence
• /
• v.11 no.9
• /
• pp.289-299
• /
• 2013

The aim of this study was to enhance the NHI claims data-based tuberculosis classification rule of KCDC(Korea centers for disease control & prevention) for an effective TB surveillance system. 8,118 cases, 10% samples of 81,199 TB cases from NHI claims data during 2009, were subject to the Medical Record Survey about whether they are real TB patients. The final study population was 7,132 cases whose medical records were surveyed. The decision tree model was evaluated as the most superior TB patients detection model. This model required the main independent variables of age, the number of anti-tuberculosis drugs, types of medical institution, tuberculosis tests, prescription days, types of TB. This model had sensitivity of 90.6%, PPV of 96.1%, and correct classification rate of 93.8%, which was better than KCDC's TB detection model with two or more NHI claims for TB and TB drugs(sensitivity of 82.6%, PPV of 95%, and correct classification rate of 80%).

• Journal of dental hygiene science
• /
• v.15 no.6
• /
• pp.815-824
• /
• 2015

This study aims to figure out the current state of health insurance education provided to dentists and personnel in charge of insurance claim as well as the effects of experiences in education on their knowledge of health insurance standard and actual application. As a result of analysis on 100 data sheets related to dentistry and 100 data sheets related to personnel in charge of insurance claim (a total of 200 data sheets), following results were generated. Insurance claim personnels showed higher score than dentist in knowledge of health insurance standard and it was significant statistically. Knowledge of insurance claim personnel showed significant differences in educational experiences, in health insurance for the latest three years and average hours of education per session whereas that of dentists did not indicate any significant differences. The level of practical application of dentists was significantly different (p<0.05) according to experiences in insurance claim, and that of insurance claim personnel significantly varied (p<0.05) depending on age, experiences of insurance education and average hours of education. The longer average hours of education, the higher level of practical application. Experiences of insurance education turned out to affect on the knowledge of health insurance standard significantly (p<0.05) on the part of dentists and insurance claim personnel, and the level of experiences in insurance claim and knowledge of health insurance standard on the part of dentists and insurance claim personnel turned out to affect on practical application significantly (p<0.001). Judging from the result, continuous education needs to be conducted in order to enable dentists and insurance claim personnel to maintain the level of knowledge about health insurance and practical application.

• 한국IT서비스학회:학술대회논문집
• /
• 2010.05a
• /
• pp.9-16
• /
• 2010

대한민국의 의료보험은 크게 국가에서 운영하는 국민건강보험과 국민이 선택적으로 가입하는 민간의료보험으로 나눌 수 있다. 국민건강보험과는 달리 민간의료보험 청구와 정산은 각 보험사별로 이루어지고, 또한 그 절차도 각자 독자적인 방법과 순서를 따라 진행되어 보험가입자의 불편 해소 및 업무의 효과적 추진을 위한 방안이 모색되어왔다. 이에 민간의료보헙협의체(KPPO)에서는 2009년부터 HNIP의 바로One 서비스를 통하여 병원, 보험회사, 보험가입자를 연계하는 보험 청구 및 지원서비스를 개발하여 운영하고 있다. 의료기관-보험사-보험가입자를 연계하는 전략적 협력 융합 서비스 구축을 토대로, 기존에 서로 연계되지 않고 오프라인으로 진행되던 보험금 청구 프로세스를 효과적이고 체계적인 관계로 발전시켰다. 그리고, 다자간의 새로운 정보 유통망의 구축 및 융합 서비스를 통하여 업무의 표준화, 다자간의 관련 업무 프로세스의 효율화를 도모하였다. 이러한 융합서비스를 통하여 규모의 경제, 고객의 편의 및 만족 증대, 기업의 사회적 책임 달성, 신뢰의 구축 등 융합서비스 구축의 다양한 시너지효과를 기대한다.

• Journal of dental hygiene science
• /
• v.11 no.1
• /
• pp.31-35
• /
• 2011

The purpose of this study was to examine the state of the claim of dental clinics for payment from the national health insurance corporation in a bid to provide some information on the efficient management of payment claim by dental institutions. The findings of the study were as follows: As for the form of payment claim, 45.4 percent claimed payment by themselves, and 54.6 percent asked an agent to do that on behalf of them. Concerning the type of occupation of the applicants, dental hygienists demanded payment in the biggest number of the dental clinics(78.2%). The most common number of cases that the dental clinics demanded payment was between 201 and 400(40.3%). The dental clinics asked an agent to claim payment when the number of payment claim cases was smaller, and they claimed payment by themselves when the number of payment claim cases was larger. Regarding the reason why the dental institutions asked an agent for payment claim, the biggest group(28.0%) cited complicated claim procedure as the reason, and the second largest group(22.6%) answered that they weren't used to doing that. The third greatest group(20.8%) pointed out a shortage of personnels that would be responsible for that as the reason.

• Journal of Digital Convergence
• /
• v.14 no.4
• /
• pp.231-237
• /
• 2016

The private health insurance covers areas that are not covered by the national health insurance to reinforce insurance guarantee. Realistically, however, many people renunciate small sum insurance claims because the inconvenient claim procedures require a certificate from the hospital for resubmission to the insurance company, which is very time consuming. Therefore, One-stop insurance payout claiming system that is capable of one stop processing of the issuance of e-page safer technology-based certification to claiming of insurance payout by utilizing authorized electronic address (#-mail) through the utilization of private information concealment technology and identification certification technology for the convenience of the subscribers and the simplification of operation was developed.

• Proceedings of the Korean Operations and Management Science Society Conference
• /
• 2006.05a
• /
• pp.1667-1676
• /
• 2006

다른 산업과 달리 병원/의료 산업에서는 건강 보험료 심사 평가라는 독특한 검증 과정이 필수적으로 있게 된다. 건강 보험료 심사 평가는 병원의 수익 문제 뿐 아니라 적정한 진료행위를 하는 병원이라는 이미지와도 맞물려 매우 중요한 분야이며, 특히 대형 종합병원일수록 이 부분에 많은 심사관련 인력들을 투입하여, 병원의 수익과 명예를 위해서 업무를 수행하고 있다. 본 논문은 이러한 건강보험료 청구 심사 과정에서, 사전에 수많은 진료 청구 건 중 심사 평가에서 삭감이 될 수 있는 진료 청구 건을 데이터 마이닝을 통해서 발견하여, 사전의 대비를 철저히 하고자 하는 한 국내의 대형 종합병원의 사례를 소개하고자 한다. 데이터 마이닝을 적용함에 있어, 주요한 문제점 중의 하나는 바로 지도학습 기법을 적용하기에 곤란한 데이터 불균형 문제가 발생하는 것이다. 이런 불균형 문제를 해소하고, 비교 조건 중에 가장 효율적인 삭감 예상 진료 건 탐지 모형을 만들어 내기 위하여 데이터 불균형 문제의 기본 해법인 과, Sampling 오분류 비용의 다양하고 혼합적인 적용을 통하여, 적합한 조건을 가지는 의사결정 나무 모형을 도출하였다.

• Journal of Digital Convergence
• /
• v.19 no.9
• /
• pp.317-322
• /
• 2021

This study focuses on user experience of Ant Insurance Platform(insurance product of Alibaba) and provides insights and improvement advises based on the survey conducted. Given that insurance claim is the most controversial part during the whole process, it is essential to conduct corresponding research from users' prospective. Some Chinese users between their 20's and 40's, who are major users of mobile insurance platforms, were selected as a sample group. Questionaire survey, which was made based on measurement items from Information systems success model, as well as in-depth interview was conducted within the group. According to the result, health, among all kinds, is the most difficult insurance to claim, which was mainly cause by security and information concerns. In order to enhance security, more options should be given to users. As for information, complains should be delt carefully and transparently. This study is expected to be used as referential material for mobile insurance platforms and user experience of insurance claims.

• The Korean Society of Law and Medicine
• /
• v.16 no.2
• /
• pp.87-130
• /
• 2015

In a case in which National Health Insurance Corporation (NHIC) pays medical care expenses to a victim of a traffic accident resulting in injury or death and asks the assailant for compensation of its share in the medical care expenses, as the precedent treats the subrogation of a claim set by National Health Insurance Act the same as that set by Industrial Accident Compensation Insurance Act, it draws the range of its compensation from the range of deduction, according to the principle of deduction after offsetting and acknowledges the compensation of all medical care expenses borne by the NHIC, within the amount of compensation claimed by the victim. However, both the National Health Insurance Act and the Industrial Accident Compensation Insurance Act are laws that regulate social insurance, but medical care expenses in the National Health Insurance Act have a character of 'an underinsurance that fixes the ratio of indemnification,' while insurance benefit on the Industrial Accident Compensation Insurance Act has a character of full insurance, or focuses on helping the insured that suffered an industrial accident lead a life, approximate to that in the past, regardless of the amount of damages according to its character of social insurance. Therefore, there is no reason to treat the subrogation of a claim on the National Health Insurance Act the same as that on the Industrial Accident Compensation Insurance Act. Since the insured loses the right of claim acquired by the insurer by subrogation in return for receiving a receipt, there is no benefit from receiving insurance in the range. Thus, in a suit in which the insured seeks compensation for damages from the assailant, there is no room for the application of the legal principle of offset of profits and losses, and the range of subrogation of a claim or the amount of deduction from compensation should be decided by the contract between the persons directly involved or a related law. Therefore, it is not reasonable that the precedent draws the range of the NHIC's compensation from the principle of deduction after offsetting. To interpret Clause 1, Article 58 of the National Health Insurance Act that sets the range of the NHIC's compensation uniformly and systematically in combination with Clause 2 of the same article that sets the range of exemption, if the compensation is made first, it is reasonable to fix the range of the NHIC's compensation by multiplying the medical care expenses paid by the ratio of the assailant's liability. This is contrasted with the range of the Korea Labor Welfare Corporation's compensation which covers the total amount of the claim of the insured within the insurance benefit paid in the interpretation of Clauses 1 and 2, Article 87 of the Industrial Accident Compensation Insurance Act. In the meantime, there are doubts about why the profit should be deducted from the amount of compensation claimed, though it is enough for the principle of deduction after offsetting that the precedent took as the premise in judging the range of the NHIC's compensation to deduct the profit made by the victim from the amount of damages, so as to achieve the goal of not attributing profit more than the amount of damage to a victim; whether it is reasonable to attribute all the profit made by the victim to the assailant, while the damages suffered by the victim are distributed fairly; and whether there is concrete validity in actual cases. Therefore, the legal principle of the precedent concerning the range of the NHIC's compensation and the legal principle of the precedent following the principle of deduction after offsetting should be reconsidered.