• Title/Summary/Keyword: healthcare insurance

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Legal Issues on Deception of Fraud and Abuse of Paid Medical Expenses (요양급여비용 허위청구와 사기죄의 법적 쟁점)

  • Hwang, Manseong
    • The Korean Society of Law and Medicine
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    • v.14 no.2
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    • pp.11-41
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    • 2013
  • Article 347 of criminal law provides the act of deceiving another, thereby taking property or obtaining pecuniary advantage from another. On the other hand, the concepts of fraud and abuse are confused upon interpretation since the definition in National Healthcare Insurance Law is unclear, and it affects closely to the administrative measures such as surcharge levy by the period of inspection, therefore, the disputes continue in the forms of formal objection, administrative ruling and administrative litigation. This study aims to look over the legal problems on application of criminal fraud toward the abuse of 'Paid Medical Expenses(Article 57, Sections 1 and 4 of the National Health Insurance Act)'. The main issues are concept of abuse(Article 57, Sections 1 and 4 of the National Health Insurance Act), the problems of Directions of Health-Welfare Ministry on aspect of 'Nullum crimen sine lege' Principles, the proper sentenc-ing guidelines of fraud.

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Nursing Care Fraud and False Billing - With the Case Study Basis - (요양급여의 허위.부정청구 -사례연구 중심으로-)

  • Huh, Su-Jin
    • The Korean Society of Law and Medicine
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    • v.13 no.1
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    • pp.41-69
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    • 2012
  • First introduced in 1977, Korean health care system reached to national coverage in short period of time never seen before in any other countries, and rated as successful system protecting the health of the public at relatively low price. However, despite those positive evaluations, some of fraudulent medical organizations or pharmacies are hindering the sound development of the national health care system with meticulous false billing exaggerating the number of patients or the days of their treatment. To prevent aforementioned nursing home fraud and false billing, the misconduct should be punished as subject to the criminal law and severally punished for fines and payments which far exceed the expected amount of illicit gains as it is basically violation of criminal fraud, other than the forced return of illicit gains based on civil laws. Furthermore, the Health Insurance Review and Assessment Service should strengthen and complement the fraud investigators, the review process, and the professional training to raise the detection rates. It might also want to review ways to implement whistleblower rewarding system and rewards for evidences of healthcare fraud to overcome the limits of external review.

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Health-related Quality of Life of Fallers vs. Non-fallers in Community-dwelling Elderly People (지역사회거주 노인에서 낙상유경험자와 무경험자간의 삶의 질 비교)

  • Choo, Jina;Kim, Eun-Kyung
    • Journal of muscle and joint health
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    • v.19 no.3
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    • pp.373-382
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    • 2012
  • Purpose: The purpose of the study was to compare levels of health-related quality of life (HRQOL) between fallers and non-fallers among community-dwelling elderly people. Methods: A cross-sectional comparative study was conducted with the secondary analysis of 2,067 elderly people registered in S-Gu Visiting Health Care Program in Seoul, South Korea. Participants were 206 fallers and 206 non-fallers who were age- and sex-matched with fallers. HRQOL was measured by SF-8 including physical component summary (physical HRQOL) and mental component summary (mental HRQOL). Results: There were more people in the faller group having more than or equal to three chronic diseases (p<.001), living in multiplex houses (p=.004), and being dependent by the activities of daily living (ADL) (p=.001) and instrumental ADL (IADL) levels (p<.001) than those in the non-faller group. Fallers had higher levels of depression than non-fallers (p<.001). Moreover, fallers had significantly lower levels of both physical HRQOL (p<.001) and mental HRQOL (p=.001), after adjusting for number of chronic diseases, ADL, IADL, depression, healthcare insurance, and living environment. Conclusion: Among the community-dwelling elderly people, falllers had lower levels of HRQOL than non-fallers, and such a difference remained even after the adjustment for covariates. Factors that underlie the different susceptibility to HRQOL need to be explored.

Association rule thresholds of similarity measures considering negative co-occurrence frequencies (동시 비 발생 빈도를 고려한 유사성 측도의 연관성 규칙 평가 기준 활용 방안)

  • Park, Hee-Chang
    • Journal of the Korean Data and Information Science Society
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    • v.22 no.6
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    • pp.1113-1121
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    • 2011
  • Recently, a variety of data mining techniques has been applied in various fields like healthcare, insurance, and internet shopping mall. Association rule mining is a popular and well researched method for discovering interesting relations among large set of data items. Association rule mining is the method to quantify the relationship between each set of items in very huge database based on the association thresholds. There are three primary quality measures for association rules; support and confidence and lift. In this paper we consider some similarity measures with negative co-occurrence frequencies which is widely used in cluster analysis or multi-dimensional analysis as association thresholds. The comparative studies with support, confidence and some similarity measures are shown by numerical example.

Utilization of similarity measures by PIM with AMP as association rule thresholds (모든 주변 비율을 고려한 확률적 흥미도 측도 기반 유사성 측도의 연관성 평가 기준 활용 방안)

  • Park, Hee Chang
    • Journal of the Korean Data and Information Science Society
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    • v.24 no.1
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    • pp.117-124
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    • 2013
  • Association rule of data mining techniques is the method to quantify the relationship between a set of items in a huge database, andhas been applied in various fields like internet shopping mall, healthcare, insurance, and education. There are three primary interestingness measures for association rule, support and confidence and lift. Confidence is the most important measure of these measures, and we generate some association rules using confidence. But it is an asymmetric measure and has only positive value. So we can face with difficult problems in generation of association rules. In this paper we apply the similarity measures by probabilistic interestingness measure (PIM) with all marginal proportions (AMP) to solve this problem. The comparative studies with support, confidences, lift, chi-square statistics, and some similarity measures by PIM with AMPare shown by numerical example. As the result, we knew that the similarity measures by PIM with AMP could be seen the degree of association same as confidence. And we could confirm the direction of association because they had the sign of their values, and select the best similarity measure by PIM with AMP.

A Study to define the range of sample size for setting Intensive Care Unit(ICU) facility guidelines - Focused on analysis of guidelines and present of ICUs facilities by general hospitals size (중환자실 시설기준 작성을 위한 기본시설 수준 설정 연구 - 국내·외 시설기준 및 국내 종합병원 병상규모 별 시설 현황분석을 기초로 하여)

  • Yoon, Hyung Jin;Cho, Jun Young
    • Journal of The Korea Institute of Healthcare Architecture
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    • v.23 no.3
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    • pp.47-56
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    • 2017
  • Purpose : This study is a basic research to establish guidelines for healthcare facility in Korean healthcare market. As a first step, it is a main purpose for making beginning point of ICU guideline to set a basic level of ICU facility size and quality by analysis current ICU facilities and existed domestic guidelines : law, criteria of healthcare insurance review and assessment service, credit of Korea institute for healthcare accreditation. Methods : First of all, the all requirements of existed guidelines are put together and summarized. The summary is compared with that of US, UK, and Australia to know its quality difference with international market. In addition, all hospitals in Korean market are classified based on total bed number and ICU bed number to know the most occupied facility size range in the market. Second of all, by comparing 15 ICUs' current setting of the public general hospital, a general condition of ICU facility would be extracted based on function, floor area per bed, services Results : 72.8% of hospitals in Korea are belonging below 500 beds hospital. Among them 200-299 beds hospitals occupied 35.3% and are shown as the most occupied hospital size. As 15 public general hospitals are analyzed, it is clear that the more bed size and services the more ICU area per bed. As a result it is sure that the 300~500 bed may be a clear line as a general ICU condition whose function and bed number relatively consistent in the range. Implications : to keep the qualified medical environment and contemporary hospital trend, the guideline as a minimum requirement keep naturally out from current healthcare settings and should reflect their limit to reconcile with the new trend in the market.

Estimation of cost by unnecessary readmission of the tertiary hospitals (불필요한 재입원 비용 추정에 관한 연구)

  • Shin, Min Sun;Lee, Won Jae
    • Journal of the Korea Convergence Society
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    • v.8 no.12
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    • pp.149-157
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    • 2017
  • Unnecessary readmissions could be the result of the inadequate and unnecessary treatments. Adequate quality indicators for readmission are important because they can identify inadequate spending by inpatients as well as quality screening. This study attempted to estimate the cost incurred by unnecessary readmissions. The Health Insurance Claims Data of 18 years or older who were admitted in the tertiary hospitals in 2014 were analyzed. Admissions and readmissions were sorted and readmissions were classified into planned and unplanned readmissions. We adopted 28 days as a criteria for the classification of the readmission. Proportion of the patients were higher in readmissions among cancer, accompanied diseases, and special rehabilitation patients. Cost of the readmissions were 50% of the total cost of the admission among the patients of same diseases, same departments, and same hospitals. Almost 1,000billion Won were used by the unnecessary readmissions. We need to reduce the readmissions in regions, departments, and diseases studying the pattern of the readmissions. National level efforts are required to improve quality of care and reduce cost by the unnecessary readmissions.

Distribution of medical status and medications in elderly patients treated with dental implant surgery covered by national healthcare insurance in Korea

  • Lee, Kyungjin;Dam, Chugeum;Huh, Jisun;Park, Kyeong-Mee;Kim, Seo-Yul;Park, Wonse
    • Journal of Dental Anesthesia and Pain Medicine
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    • v.17 no.2
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    • pp.113-119
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    • 2017
  • Background: The purpose of this study was to investigate the distribution of systemic diseases and medications in patients older than 65 years of age who visited the hospital for implant treatment, as well as to investigate basic information about surgical complications that may occur after insured implant treatment. Method: A total of 126 patients over 65 years of age were treated for implant surgery from October 1, 2013 to October 30, 2016. Electronic chart review was conducted to obtain medical records, which included sex, age, systemic diseases, medication(s) being taken, and control of the medications. Five patients were excluded due to lack of medical records giving information about systemic disease. Results: Of the 126 patients, 112 (88.9%) were taking medication due to systemic disease and 9 patients (7.1%) were not. The sex distribution was 71 women and 55 men and the highest proportion of patients were between 65 and 69 years old. The most common diseases were, from most to least frequent, hypertension, cardiovascular disease, diabetes, and osteoporosis. The drug groups that can cause major complications after dental treatment were classified as hemorrhagic, osteoporotic, and immunosuppressive agents, and were taken by 45 (35.7%), 22 (17.5%) and 4 (3.2%) patients, respectively. Conclusion: Given that 88.9% of the elderly patients who were eligible for insurance implant treatment had systemic disease, it is necessary to carefully evaluate patients' medical histories and their general conditions in order to prevent emergencies during implant surgery.

Poor People and Poor Health: Examining the Mediating Effect of Unmet Healthcare Needs in Korea

  • Kim, Youngsoo;Kim, Saerom;Jeong, Seungmin;Cho, Sang Guen;Hwang, Seung-sik
    • Journal of Preventive Medicine and Public Health
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    • v.52 no.1
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    • pp.51-59
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    • 2019
  • Objectives: The purpose of this study was to estimate the mediating effect of subjective unmet healthcare needs on poor health. The mediating effect of unmet needs on health outcomes was estimated. Methods: Cross-sectional research method was used to analyze Korea Health Panel data from 2011 to 2015, investigating the mediating effect for each annual dataset and lagged dependent variables. Results: The magnitude of the effect of low income on poor health and the mediating effect of unmet needs were estimated using age, sex, education level, employment status, healthcare insurance status, disability, and chronic disease as control variables and self-rated health as the dependent variable. The mediating effect of unmet needs due to financial reasons was between 14.7% to 32.9% of the total marginal effect, and 7.2% to 18.7% in lagged model. Conclusions: The fixed-effect logit model demonstrated that the existence of unmet needs raised the likelihood of poor self-rated health. However, only a small proportion of the effects of low income on health was mediated by unmet needs, and the results varied annually. Further studies are necessary to search for ways to explain the varying results in the Korea Health Panel data, as well as to consider a time series analysis of the mediating effect. The results of this study present the clear implication that even though it is crucial to address the unmet needs, but it is not enough to tackle the income related health inequalities.

A Study on the design of the outpatient and inpatient conversion factors based on the medical expenditure budget system (진료비 예산에 기초한 외래 및 입원 환산지수 설계에 관한 연구)

  • O, Dongil
    • Journal of the Korea Academia-Industrial cooperation Society
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    • v.21 no.2
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    • pp.470-478
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    • 2020
  • In this paper, a theoretical model that separates one single conversion factor into two conversion factors for both outpatients and inpatients is introduced. By using hypothetical numbers, two conversion factors and an adjustment factor were calculated. The major implications are as follows. Firstly, by introducing two conversion factors, a minimum incentive mechanism for admitting outpatients to a clinic and high risk inpatients to a hospital was installed. Secondly, the introduction of two conversion factors decreased the drive to admit outpatients to a hospital by reducing the economic benefits for the hospital. Thirdly, it is possible to make explicit contracts for several factors rather than a single conversion factor, so that it can be used as an appropriate management tool for rapidly increasing medical expenses. Finally, this research can be used to set up policy tools to establish a proper healthcare delivery system in Korea by inducing behavioral changes in healthcare institutions.