• Title/Summary/Keyword: insurance claims

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Usefulness of medical review in the insurance claims

  • Lee, Eui-Kwan;Hwang, Jin-Sup;Lee, Sin-Hyung
    • The Journal of the Korean life insurance medical association
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    • v.28 no.1_2
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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.

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Claims Insurance Medicine (클레임보험의학)

  • Lee, Sin-Hyung
    • The Journal of the Korean life insurance medical association
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    • v.30 no.2
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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.

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Differentiation between malignant and benign in terms of insurance claims (보험의학적 악성도평가)

  • Lee, Sinhyung
    • The Journal of the Korean life insurance medical association
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    • v.32 no.1
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    • pp.21-27
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    • 2013
  • In case of neoplasm claims, it is important to make a decision of differentiating malignant and benign. In Korean insurance market, there are many insurance products that cover cancer. In the insurance claims adjustment, differentiation between malignant and benign is according to histologic findings. However there are many neoplasms of bad clinical course in spite of benign histopathologic classification. In this article; astrocytoma, thymoma, gastrointestinal stromal tumor, colonic intramucosal carcinoma, gastric high grade adenoma/dysplasia, carcinoid tumor, MALT lymphoma, revision of Korean Classification of Disease-6th edition, and bladder tumors are reviewed in terms of differentiation between malignant and benign in the insurance claims. It may be helpful for claims staff to review important neoplasms in terms of differentiation between malignant and benign.

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Role of the medical claims review (의적클레임검토의 역할 및 기능)

  • Lee, Sin-Hyung
    • The Journal of the Korean life insurance medical association
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    • v.26
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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.

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Smoldering multiple myeloma which was claimed for multiple myeloma : a case report of medical claims review (다발골수종으로 청구한 무증상다발골수종 클레임의료자문 증례)

  • Lee, Sin-Hyung
    • The Journal of the Korean life insurance medical association
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    • v.29 no.2
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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.

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Application of Reinforcement Learning in Detecting Fraudulent Insurance Claims

  • Choi, Jung-Moon;Kim, Ji-Hyeok;Kim, Sung-Jun
    • International Journal of Computer Science & Network Security
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    • v.21 no.9
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    • pp.125-131
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    • 2021
  • Detecting fraudulent insurance claims is difficult due to small and unbalanced data. Some research has been carried out to better cope with various types of fraudulent claims. Nowadays, technology for detecting fraudulent insurance claims has been increasingly utilized in insurance and technology fields, thanks to the use of artificial intelligence (AI) methods in addition to traditional statistical detection and rule-based methods. This study obtained meaningful results for a fraudulent insurance claim detection model based on machine learning (ML) and deep learning (DL) technologies, using fraudulent insurance claim data from previous research. In our search for a method to enhance the detection of fraudulent insurance claims, we investigated the reinforcement learning (RL) method. We examined how we could apply the RL method to the detection of fraudulent insurance claims. There are limited previous cases of applying the RL method. Thus, we first had to define the RL essential elements based on previous research on detecting anomalies. We applied the deep Q-network (DQN) and double deep Q-network (DDQN) in the learning fraudulent insurance claim detection model. By doing so, we confirmed that our model demonstrated better performance than previous machine learning models.

Insurance Claims Review and Assessment Task Effects on the Insurance Claims Reviewer and Evaluator in Hospitals (병원 급 보험심사자의 업무 특성에 따른 효과 분석)

  • Lee, Ko-Eun;Kim, Kyung-Hwa
    • The Korean Journal of Health Service Management
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    • v.11 no.1
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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.

Review of the coronary artery disease in terms of insurance medicine (관상동맥질환의 보험의학적 이해)

  • Lee, Sinhyung
    • The Journal of the Korean life insurance medical association
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    • v.32 no.2
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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.

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A Trend of International Business Claims and Some Improvable Issues of the Korean Trade Insurance System (무역클레임의 동향과 무역보험제도의 개선과제)

  • Seo, Jung-Doo
    • THE INTERNATIONAL COMMERCE & LAW REVIEW
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    • v.49
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    • pp.189-212
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    • 2011
  • As the international business increases among the nations of the world recently, it is an inevitable fact that its claims rise as well. The most reasons of the international business claims have been concentrated upon the unpaid issues. The other reasons are sequently the different interpretation of business contract's conditions, the inferior quality of the goods, the breach of shipping time, the uncertain market-claims and some problems of transportation, the quantity and bad package of the goods. As business transactions grow more complex, it becomes increasingly important to resolve claims as quickly and efficiently as possible. Recognizing the importance of comprehensive policy support for overall international trade and investment of local company in recent years, Korean government has reborn the Korea Insurance Corporation ("K-sure"). K-sure adopted a range of measures to improve management efficiency to strengthen national competitiveness and national economy by promoting oversea trade and investment. Especially, K-sure will be able cover not only export transactions but also import transactions to secure oversea natural resources and commodities vital the national economy. K-sure should be able to continue and expand the existing export insurance programs, support import transactions and lead export-oriented industrialization of Korea as the best trade insurance agency.

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A Comparison of the Cancer Incidence Rates between the National Cancer Registry and Insurance Claims Data in Korea

  • Seo, Hee Jung;Oh, In-Hwan;Yoon, Seok-Jun
    • Asian Pacific Journal of Cancer Prevention
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    • v.13 no.12
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    • pp.6163-6168
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    • 2012
  • Although much health services research has been conducted using national health insurance claims data in Korea, the validity of this method has not been ascertained. The objective of this study was to validate the use of claims data for health services research by comparing incidence rate of cancers found using insurance claims data against rates of the national cancer registry of Korea. An algorithm to estimate incidence rates using claims data was developed and applied. The claims data from 2005-2008 were acquired and the patients admitted to hospitals due to cancer in 2008 without admission to hospital from 2005-2007 by the same diagnosis code were regarded as incident cases. The acquired results were compared with the values from the National Cancer Registry of Korea. The incidence rate of all cancers found using claims data was 363.1 per 100,000 people, which is very similar to the 361.9 per 100,000 rate of the national cancer registry. Also the age-, gender- and disease-specific rates between the two data sources were similar. Therefore, national health insurance claims data may be a worthwhile resource for health services research if appropriate algorithms are applied, especially considering the cost effectiveness of this method.