• 보험의학회지
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• 제26권
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• pp.41-53
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• 2007

In the course of insurance claim administration, medical experts' opinions are called medical claim reviews. They are classified into two main categories: medical verification and counsel for claim staff. Medical verification compare between product coverage and the insured's physical condition. Medical counsel for claim staff is advice for claim staff when they have a question about medical knowledge to make a claim decision. A common example of medical verification is insurance coding of pituitary apoplexy. Some clinicians have insisted that the ICD coding of pituitary apoplexy is l63 of cerebral infarction, but the exclusion criteria of I code show that neoplasm is coded as C00 to D48. Thus, pituitary apoplexy must be coded as D33. An example of medical counsel for claim staff is interpretation of some medical conditions. It is divided into UCR(usual, customary, and reasonable) assessment, assessment of causality, and so on. Disability evaluation is another subject of medical counsel for claim staff. The final claim decision must be made by claim staff because only the claim staff have the authority of claim decision. Medical claims review is only an expert's opinion.

• 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.

• 한국병원경영학회지
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• 제10권2호
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• pp.45-63
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• 2005

The purposes of this study are to understand the doctors' attitude and satisfaction about the review system of national health insurance claim in Korea and to suggest the way to improve this system This study conducted a survey of the doctors registered in the medical association in Seoul city. The survey was performed as a form of self-administered questionnaire from January 2004 to February 2004. The contents of questionnaire dealt with doctors' attitude and satisfaction about the review system of medical service claim. Totally, 1,037 members replied to our survey and we analysed 981 doctors' data, excluding incomplete responses. As a result, 89.7% of repliers showed a negative attitude about the influences of the review system on improvement of medical service quality, 98.0% of repliers have had experiences that they have given distorted insufficient medical services in order to evade the curtailment of service claim. Also, 91.6% of repliers stated that they have had experiences of intentional modification or alteration of diagnostic code to shun the curtailment. Most of the doctors showed negative attitude to the curtailment procedure and the review system of service claim originally intended to be one of the quality control methods of medical service in Korea also, the development of both scientific and reasonable parameters and criteria for claim is needed. 'Through the improvement of review system for appropriate medical service, there is a need of a way to increase the satisfaction of medical service providers, and to encourage the motivation for quality control. Also, education is strongly needed to provide doctors with sufficient information about review criteria and curtailment cases.

• 보건행정학회지
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• 제14권4호
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• pp.88-113
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• 2004

Starting from April, 2003, new pre-review system has been introduced and implemented to reduce unnecessary conflict with medical care organizations caused by current retrospective claim review system and to enhance efficiency of review system. The main purpose of pre-review system is to educate doctors to contrive adequacy of medical services. This research mainly focuses on effectiveness of pre-review system's influence on physicians' behavior changes. The analysis-participants were drawn from 1,449 clinics which implemented pre-review system, since April of 2003. The research results are as followings. First, the amount per claim has reduced by $\\3,154$, days of visit per claim by 0.1 day, and amount per visit by $\\412$, which were statistically significant. Second, anesthesiologists have decreased in three indicators the most, and the internists had least of changes. Third, the amount per claim and days of visit per claims has dropped significantly on physicians with less periods of practice and physicians with more ages. Fourth, the clinics without the expensive medical equipments, the city clinics showed significant decrease on days of visit per claim. Fifth, in intervention methods, the one-to-one education showed more significant decrease on amount per visit rather than information feedback by paper. In conclusion, the pre-review system have an impact on self-imposed physician behavioral change. The outcome of this research may be utilized for future extension implementation of pre-review system. Furthermore, it is showed that ability of transitions in medical services review system according to the future transition of payment system and context of health service policy.

• 한국병원경영학회지
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• 제9권3호
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• pp.71-97
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• 2004

This study conducted a comparative analysis of awareness level of review standards, continuing education, and awareness about the need for speciality and educational courses in order to improve quality of Korean health insurance review work and to present directions for policies of personnel development and continuing education to smoothly perform hospital's insurance claim work and Agency's review work. The analysis unit of the study is individuals, and survey was conducted among hospital's claim officers and Agency' review officers by distributing questionnaires. The major results of the study are as follows: First, it is found that hospital's claim officers and Agency's review officers have conflicting awareness about review standards; more Agency's review officers think that current review standards are universal and reasonable, while more hospital's claim officers believe that they need to be revised. Especially, hospital's claim officers replied that it is possible that review results can differ according to government's policies. Second, there is no significant difference between the two groups in the opinion that there are individual differences in awareness level of review standard. In particular, both groups share the opinion that review results can differ according to officer's interpretation of review standards. Third, Both review officer groups feel the need for further training and continuing education. Fourth, there is no difference between the two groups in the opinion that both groups members should be educated in review related educational institutions. However, while 81.5% of Agency's review officers the education should be offered at the Agency, only 45.2% of hospital's claim officers agreed to it. Fifth, both review personnel do not show any difference in awareness of needed experience to successfully perform review work; both groups replied that three to four years experience is necessary to smoothly perform claim work and review work. This study was tried in order to search for directions to improve Korean insurance review work in quality rather than to explore characteristics themselves of individual factors. In this sense, this study presupposed an intention that the educational subjects for further training and continuing education for the two groups should be the same in order to narrow the awareness gap between hospital's claim officers and Agency's review officers. Thus, this study suggests that it is desirable to offer beginner courses at junior colleges or in undergraduate courses and advanced courses in professional graduate school for six to twelve months. In that a comparison of awareness level of hospital's claim officers and Agency's review officers who are actually in practice should precede appropriate presentation of directions for the qualitative improvement of insurance review work in Korea, the significance of this study lies in comparatively analyzing the awareness level of hospital's claim officers and Agency's review officers and in presenting the establishment of future further training and continuing education.

• 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.

• 보건행정학회지
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• 제26권1호
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• pp.63-70
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• 2016

Background: Selective health benefit was introduced for decreasing economic burden of patients. Medical devices with economic uncertainty have been covered as selective health benefit by National Health Insurance since December 2013. We aimed to analyze impact of selective health benefit to medical expenditure and provider behavior focused on electrosurgery (ultrasonic shears, electrothermal bipolar vessel sealers) for gastric cancer patients covered since December 2014. Methods: We used the National Health Insurance claims data of 2,698 patients underwent gastric cancer surgery between August 2014 and March 2015. Medical cost and patient sharing per inpatient day were analyzed to verify that covering electrosurgery increased medical expenditure and changed provider behavior from open surgery to endoscopic or laparoscopic surgery. Additionally, we analyzed the claim rate of medical device or goods relating gastric endoscopic and laparoscopic surgery. Results: Medical cost and patient sharing per inpatient day were increased after covering electosurgery as selective health benefit (39,724/1,421 won). However, there were no medical expenditure increases after adjusting claim of electosurgery and patient sharing was decreased 1,057 won especially. The coverage of selective health benefit did not increase the claim rate of medical device or goods related endoscopic or laparoscopic surgery, either. Conclusion: Covering electosurgery decreased patient economic burden and did not change of provider behavior. Expanding selective health benefit is needed to decrease economic burden of severe patients. Further study should evaluate the long term effect with accumulated data.

• 의료법학
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• 제8권1호
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• pp.137-177
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• 2007

The medical expenses review system in Korea has developed under fee-for-service system with its own unique structure. The importance of reviewing medical expenses has been emphasized, as the size of medical expenditures moving through the health insurance legal context and its weight in the national economy have increased very rapidly. It is, however, analyzed that the feuds and arguments continue among the stakeholders for the lack of laws supporting the medical expenses review system. The medical expenses review is a series of administrative procedures, deciding whether claims from medical care institutions to the insurer are legal and valid or not. It mainly controls the increase of unnecessarily excessive health insurance claim and prevents fraudulent claim and abuse and checks the less use or unsuitable use of medical resources. It also works a function guarantees medical benefits for the appropriate treatment according to the object of health insurance system as a social insurance scheme. The dispute on legal base of the medical expenses review is about the source of law in the medical expenses review. There are the Health Insurance Act and administrative laws as jus scriptum and the guidelines of review as administrative orders. The medical expenses review should reflect various factors, such as the development of medical healthcare technologies, the health expenditures distribution, the financial situation of the health insurance, and the evaluation on the level of appropriate benefits. It is also likely to adapt to the traits of characters of medicine, and trends and transition, Besides it should judge the legality and the validity of medical benefits expenditures by synthesizing these all factors. And the evaluation system of appropriateness of medical benefits was administrative procedure which was consecutive with reviewing the medical expenses system and it was intended to make up for the result of reviewing the medical expenses in more comprehensive levels.

• Korean Journal of Radiology
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• 제24권12호
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• pp.1179-1189
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• 2023

Objective: We aimed to evaluate the reporting quality of research articles that applied deep learning to medical imaging. Using the Checklist for Artificial Intelligence in Medical Imaging (CLAIM) guidelines and a journal with prominence in Asia as a sample, we intended to provide an insight into reporting quality in the Asian region and establish a journal-specific audit. Materials and Methods: A total of 38 articles published in the Korean Journal of Radiology between June 2018 and January 2023 were analyzed. The analysis included calculating the percentage of studies that adhered to each CLAIM item and identifying items that were met by ≤ 50% of the studies. The article review was initially conducted independently by two reviewers, and the consensus results were used for the final analysis. We also compared adherence rates to CLAIM before and after December 2020. Results: Of the 42 items in the CLAIM guidelines, 12 items (29%) were satisfied by ≤ 50% of the included articles. None of the studies reported handling missing data (item #13). Only one study respectively presented the use of de-identification methods (#12), intended sample size (#19), robustness or sensitivity analysis (#30), and full study protocol (#41). Of the studies, 35% reported the selection of data subsets (#10), 40% reported registration information (#40), and 50% measured inter and intrarater variability (#18). No significant changes were observed in the rates of adherence to these 12 items before and after December 2020. Conclusion: The reporting quality of artificial intelligence studies according to CLAIM guidelines, in our study sample, showed room for improvement. We recommend that the authors and reviewers have a solid understanding of the relevant reporting guidelines and ensure that the essential elements are adequately reported when writing and reviewing the manuscripts for publication.

• 보험의학회지
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• 제27권1호
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• pp.33-36
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• 2008

BACKGROUND : The medical claims review(MCR) is unique methodology of medical consultation in terms of insurance claim administration in Korean insurance market. The most important practical matter in the MCR is formatted question. In Korea, medical specialty is composed of 26 legally defined hospital departments. It is worth of studying to investigate type of MCR by hospital departments. METHODS : Fifty Cases of the MCR were selected randomly by statistical program SPSS among 1,032 cases which were performed between April 1, 2006 and March 31 2007. All of selected cases were evaluated one insurance doctor and made a score points from 0 to 10 in terms of hospital department. RESULTS : Multidimensional scaling was performed. The MCR types - diagnosis, malignancy and cause of death are located in the same 2-dimensional configuration area. It can be called as verification of benefit. Others are advice. - such as causality, interpretation, translation, independent medical examination, and so on. DISCUSSION : We can conclude the classification of MCR typology are two main subjects, verification and advice. Theses results are same as previous article which was based on experience.