• 보험의학회지
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• 제28권1_2호
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• pp.31-35
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• 2009

Background : Many of internists have been working for insurance industry. Insurance medicine is use of medical knowledge for insurance industry. There is social role of insurance medicine in terms of soundness of insurance administration. Recently social role of internists also have been being watched. Although theme of insurance medicine is medical risk selection, insurance claims administration also needs medical experts'opinion. There are not any corroborative study of medical consulting for insurance claims. Among insurance industry, someone called this medical review of insurance claims as 'medical claims review'. Aim : To investigate usefulness of medical review of insurance claims. Design : Questionnaire survey with claim staffs in one of insurance claim adjustment company in Korea. Methods : 265 claim staffs were divided into 4 groups and conducted survey using a questionnaire of 20 questions. Utility score, job satisfaction score, and difficult factors of claims administration were measured. Results : Utility score and job satisfaction score are highest in medical claims review group. The most difficult in claim administration to claim staffs was demonstrated to medical knowledge. Conclusion : Medical review of insurance claims is proved to be worthy. Document-based consulting method, namely medical claims review, is more useful than telephone-based simple query among claim staffs...Subjects of the medical claims review are medical record and it's principle is independent medical examination with evidence-based approach, it also has role of protecting fraud of insurance claims. Two main question types of medical claims review are verification and advice.

• 보험의학회지
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• 제26권
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• pp.31-39
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• 2007

Background and main issue: In the Korean insurance market, an outstanding issue is the decrease of margin of risk ratio. This affects the solvency and profitability of insurance companies. Insurance medicine, which has been developed in Western countries, is so-called medical risk selection or medical underwriting. Medical risk selection is based on clinical follow-up study and mortality analysis methodology. Unfortunately, there have been few clinical follow-up studies, and no intercompany disease analysis system is available in the Korean insurance market. In practice, we use underwriting guidelines, which were developed by some global reinsurance companies. However, these guidelines were developed under clinical follow-up studies performed abroad. So, we cannot rule out underestimation of excess mortality factors such as mortality ratio, excess death rate, and life expectancy. It is necessary to perform medical assessment in claims administration. Comparing the insured's statement by medical records with products' benefit according to this procedure, we can make sound claim decisions and participate in the role of sound underwriting. We can call this scientific procedure as the verification of medical claims review. Another area of medical claims review is medical counsel for claims staff. Result: There is another insurance medicine in addition to medical risk selection. Independent medical assessment by medical records of insured is medical claims review. Medical claims review is composed of verification and counsel.

• 보험의학회지
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• 제30권2호
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• pp.8-11
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• 2011

Insurance medicine has been known to medical risk selection. The role of insurance medicine is sound maintenance of insurance system. So it's function is medical underwriting of life risks. However, emerging market has insufficient medical epidemiological research that is necessary for estimation of extra-risk and such market is usually lack of full understanding of life insurance among insurance customers. This problem makes difficult of performing the medical underwriting, as an original insurance medicine. Medical contributions at the stage of claims adjudication comparing the coverage provided in the product, with the information provided in the claims, based on medical records and the agreement between them. This is called medical verification. The insurance doctors can also use their medical knowledge to help the claims staff with informing claimants about the medical basis of claims decisions.

• 한국의료질향상학회지
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• 제12권1호
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• pp.52-61
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• 2006

Background : The promotion and advertisement of pharmaceuticals should be based on evidence from clinical trials. We conducted this study to assess whether the pharmaceutical advertisement claims in Korean medical journals had relevant references, and whether the claims were supported by the references. Methods : We reviewed pharmaceutical advertisements in five Korean medical journals issued during the first half of 1999 and during the first half of 2004. Three investigators independently reviewed the advertisements to see whether the studies quoted to endorse the advertising messages supported the corresponding claims. Using multiple logistic regression analyses, we investigated which factors were associated with the quality of the advertisement claims. Results : From the 550 advertisements in the five journals, we identified 157 different advertisements and 475 different promotional claims. Only 149 claims had at least one reference, and 105 claims had references of published article. We could find supporting evidences in the 90 claims. The factors which were associated with the quality of advertisement claims were category of drugs, category of claims, and the manufacturer characteristics. Claims for cardiovascular and endocrine drugs, and claims on efficacy, and claims of multinational company were more evidence-based. Conclusion : Majority of the pharmaceutical advertisement claims in Korea did not have appropriate references. Drug category, claim category, and the manufacturer characteristics were associated with the quality of advertisement claims, and the manufacturer characteristics was the most important determinants.

• 보험의학회지
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• 제29권2호
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• pp.33-35
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• 2010

Multiple myeloma is characterized by the neoplastic proliferation of a single clone of plasma cells producing a monoclonal immunoglobulin and it is frequently associated with primary amyloidosis. I experienced a medical claims review case of plasma cell dyscrasia with primary amyloidosis. This medical consulting work to insurance claims will be helpful for another similar claims administration.

• 대한예방한의학회지
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• 제19권2호
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• pp.51-56
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• 2015

Objective : We analyzed present condition of cooperative medical care using claims data of HEALTH INSURANCE REVIEW & ASSESSMENT SERVICE form patients treated by Korean-Western cooperative medicine. The study aimed to offer guidelines in selecting disease-related research in developing Korean-Western convergence technology. Method : Based on the patients using Korean medical service, we analyzed claims data of patients using Korean medical service and western medical service from January 2012 to December 2013. We were assigned to the server remotely. With the concept of 'episode of care', we rebuilt claims data and analyzed present condition of cooperative medical usage. Results : We analyzed present condition of cooperative medical care per episode of care. Among outpatients, Low back pain, lumbar region(M5456) was the highest number. Among inpatients, Sciatica due to intervertebral disc disorder(M511) was the highest number. Conclusion : Based on the claims data provided by HEALTH INSURANCE REVIEW & ASSESSMENT SERVICE, we have derived a list of multy frequently disease frequently treated by cooperative medical care by analyzing present condition.

• Journal of Preventive Medicine and Public Health
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• 제34권1호
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• pp.28-34
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• 2001

Objectives : To investigate the changing pattern of medical utilization claims following the economic crisis in Korea. Methods : The original data consisted of the claims of the 'Medical insurance program of self-employees' between 1997 and 1998. The data was selected by medical treatment day ranging between 8 January and 30 June. Medical utilizations were calculated each year by the frequency of claims, visit days for outpatients, length of stay for inpatients, total days of medication, and the sum of expenses. Results : The length of stay as an inpatient in 1998 was decreased 4.7 percent in comparison to 1997. However, inpatient expenses in 1998 increased 10.8 percent as compared to 1997. Inpatient hospital claims in 1998 increased 6.2 percent over 1997, although general hospital inpatient claims in 1998 decreased 3.3 percent in comparison to 1997. The outpatient claim frequency decreased 7.3 in 1998 percent as compared to 1997 Outpatient visit days of in 1998 were decreased 8.5 percent in comparison to that recorded in 1997. Outpatient claim frequencies of 'gu region' in 1998 decreased 10.5 percent comparison to that in 1997, but 'city and gun region' decreased less than 'gu region'. Conclusions : Medical utilization in 1998 deceased in relation to 1997 Medical utilization by outpatients decreased more than that of inpatients. Medical utilization by 'gu region' decreased mere than the other regions.

• Journal of Preventive Medicine and Public Health
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• 제28권3호
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• pp.640-650
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• 1995

After the introduction of National Medical Insurance in 1989, the medical demand has rapidly increased. The impact of increased medical demand was followed by an increase in the number of claims in need of review. We studied a new, fair method for reducing the number of claims reviewed. We analysed 90,583 outpatient claims submitted between September and October; claims were made for services given August of 1994. We finally suggested a screening system for claims review using a statistical method of discriminant analysis of the medical costs. The results were as follows. 1. In the cut-off group, age, days of medication, number of hospital or clinic visits, and total charge were significantly high. The cut-off rates according to the hospital-type and existence of accompanied disease were significantly different 2. According to ICD, the cut-off rate was highest in peripheral enthesopathies and allied syndromes(20.76%), lowest in acute sinusitis(0.93%). The mean charges were significantly different according to ICD and existence of cut-off. 3. We build discriminant functions by ICD with such discriminant variables as patient age, sex, existence of accompanied disease, number of hospital or clinic visits, and 9 detailed hospital or clinic charges included in claim. 4. We applied the discriminant function for screening those claims that were expected to be cut-off. The sensitivities comprised from 40% to 70%, and specificities from 70% to 95% by ICD. Acute rhinitis had highest sensitivity(100.00%) and other local infections of skin and subcutaneous tissue had highest specificity(98.45%). The expected number of cut-off was 17,762(19.61%). The total sensitivity was 49.62%, the total specificity was 82.57% and the error rate was 19.66%. We lacked economic analysis such as cost-benefit analysis. But, if the new method of screening claims using discriminant analysis were applied, the number of claims in need of review will reduce considerably.

• 보건행정학회지
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• 제27권1호
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• pp.30-38
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• 2017

Background: This study aims to analyze the behavioral changes of healthcare providers and influencing factors after the reviewer unification of auto insurance medical benefit claims by an independent review agency. Methods: The comparison data were collected from the second half of 2013 and the same period of 2014. The key indicators are the number of admission days, the number of outpatient visits, inpatient ratio, inpatient medical expenses, and outpatient medical expenses. Results: Four indicators (number of admission days, number of outpatient visits, inpatient ratio, and outpatient medical expenses) showed statistically significant drops, while one indicator (inpatient medical expenses) showed no significant change. Conclusion: The reviewer unification of auto insurance medical benefit claims by an independent review agency showed significant reduction in cost and patient days.

• 보험의학회지
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• 제24권
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• pp.27-42
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• 2005

Among medical claims review, decision of malignancy is very important. According to the pathologic report may be ordinary pathway. Some tumors are not completely studied especially malignancy. Wheather malignancy or benign is the important thing in medical claims review. We here disscuss on the debatable tumors such as carcinoid tumor, gastrointestinal stromal tumor (GIST), desmoid tumor, MALToma, and pseudomyxoma peritonei. Another controversial subject in the medical claims review is selection of pathologic report. If the result of the pathologic report is not same in one patient, We prefer the selsection of the report from more professional hospital. We have called this professional hospital l as "third hospital" or 'refferal hospital".