• 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.

• 보건의료산업학회지
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• 제11권1호
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• pp.27-42
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• 2017

Objectives : This study analyzes the characteristics of hospital organization structures, insurance claims reviews and assessment tasks and their effects on hospitals in Pusan. Methods : The data for this study were collected through interview and self-administered surveys in 109 hospitals. The study included only - hospitals with a minimum of 50beds and excluded those providing only dental, psychiatric, or long-term care. Results : The findings of this study state that the number of beds has an influence on the organizitional structure. Conclusions : Hospital managements should seek human resources management(the insurance claims reviewer and evaluator) schemes that take into account the characteristics of the medical institution. In addition, insurance claims review and assessment tasks in hospitals require considerable knowledge and experience, and hospitals should be equipped with staff that have the relevant expertise. Therefore, to further deepen knowledge, comprehensive training should be continuously carried out in order to produce specialists in claims review and assessment.

• 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.

• 보건행정학회지
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• 제16권2호
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• pp.49-76
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• 2006

The aim of this study was to explore the effects of a computerized review program which was introduced in August 1, 2003, using claims data for acute respiratory infection related diseases. National Health Insurance (NHI) claims data on respiratory infection related diseases before and after the introduction, with six month intervals respectively, were used for the analysis. Clinic was the unit of observation, and clinics with only one physician whose specialty was internal medicine, pediatrics, otorhinolaryngology and family medicine and clinics with a general practitioner were selected. The final sample had 7,637 clinics in total. Indices used to measure practice pattern was prescription rates of antibiotics, prescription rates of injection drug per visit, treatment costs per claim, and total costs per claim. Changes in the number of claims for major disease categories and upcoding index for disease categories were used to measure claiming behavior. Data were analysed using descriptive analysis, t-test for indices changes before and after the introduction, analysis of variance (ANOVA) for practice pattern change for major disease categories, and multiple regression analysis to identify whether new system influenced on provider' practice patterns or not. Prescription of antibiotics, prescription rates of injection drug, treatment costs per claim, and total costs per claim decreased significantly. Results from multiple regression analysis showed that a computerized review system had effects on all the indices measuring behavior. Introduction of the new system had the spillover effects on the provider's behavior in the related disease categories in addition to the effects in the target diseases, but the magnitude of the effects were bigger among the target diseases. Rates of claims for computerized review over total claims for respiratory diseases significantly decreased after the introduction of a computerized review system and rates of claims for non target diseases increased, which was also statistically significant. Distribution of the number of claims by disease categories after the introduction of a computerized review system changed so as to increase the costs per claims. Analysis of upcoding index showed index for 'other acute lower respiratory infection (J20-22)', which was included in the review target, decreased and 'otitis media (H65, H66)', which was not included in the review target, increase. Factors affecting provider's practice patterns should be taken into consideration when policies on claims review method and behavior changes. It is critical to include strategies to decrease the variations among providers.

• 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.

• 한국병원경영학회지
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• 제28권3호
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• pp.47-57
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• 2023

Purpose: Health expenditure and utilization of Korean medicine are increasing every year. Since Chuna Manual Therapy was covered by National Health Insurance in 2019, it is predicted that the usage of Chuna Manual Therapy would be also increasing. However, there are few studies about Chuna Manual Therapy using Korean National Health Insurance claims database. Therefore, we will investigate the utilization trend of outpatient's Chuna Manual Therapy using Korean National Health Insurance database and suggest political implications. Methodology: The Korean National Health Insurance claims database was used to identify outpatient's Chuna Manual Therapy usage spanning 4 years from 2019-2023 and the number of Chuna Manual Therapy claims were approximately 18.61 million. Findings: The number of Chuna Manual Therapy claims and patients, health expenditure of Chuna Manual Therapy have been increasing spanning 4 years among over 65 aged. In the case of female patients, the number of Chuna Manual Therapy claims was more than male patients and health spending related to Chuna Manual Therapy was also higher than male patients. Most patients visited Korean medicine clinics due to musculoskeletal diseases, and most claims were from rural regions. Practical Implication: Since Chuna Manual Therapy was covered by National Health Insurance in 2019, Utilization of Chuna Manual Therapy has been increased overall. In particular, Chuna Manual Therapy is mostly implemented in the elderly, Korean medicine clinics, and local areas, thus policy managers will need to consider this.

• 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".

• 보험의학회지
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• 제32권2호
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• pp.33-38
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• 2013

Coronary artery diseases are very important agenda in the insurance medicine. Insurance medicine is defined as using medical knowledge for insurance administration such as underwriting, claims, and customer satisfaction. This review article contains review of coronary artery disease in terms of insurance medicine. Estimation of extra-risks for acute myocardial infarction are MR of 349% and EDR of 41‰. In medical underwriting, individual life applicants can be assessed by Framingham's CHD risk assessment model. In claims, medical claims review is a useful method of consulting for claims staffs. Several diagnostic criteria of acute myocardial infarction are introduced in time. The universal definition of myocardial infarction by ESC/ACCF/WHF was demonstrated the most valuable predictor of 10-year mortality. Contents for State-Of-The-Art of the coronary artery disease are current antithrombotics. There are many novel anti-thrombotic agents such as ticagrelol, dabigatran, rivaroxaban, and pegnivacogin.

• 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.