• Health Policy and Management
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• v.13 no.1
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• pp.98-115
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• 2003

Concerns about growing health insurance expenditures became a national Issue in 2001 when the National Health Insurance went into a deficit. Increases in spending for ambulatory care shared the largest portion of the problem. Methods and systems to control the spending should be developed and a system to measure case mix of providers is one of core components of the control system. The objectives of this article is to examine the feasibility of applying Korean Diagnosis Related Groups (KDRGs) to classify health insurance claims for ambulatory care and to identify problem areas of the classification. A database of 11,586,270 claims for ambulatory care delivered during January 2002 was obtained for the study, and the final number of claims analyzed was 8,319,494 after KDRG numbers were assigned to the data and records with an error KDRG were excluded from the study. The unit of analysis was a claim and resource use was measured by the sum of charges incurred during a month at a department of a hospital of at a clinic. Within group variance was assessed by th coefficient of variation (CV), and the classification accuracy was evaluated by the variance reduction achieved by the KDRG classification. The analyses were performed on both all and non-outlier data, and on a subset of the database to examine the validity of study results. Data were assigned to 787 KDRGs among 1,244 KDRGs defined in the classification system. For non-outlier data, 77.4％ of KDRGs had a CV of charges from tertiary care hospitals less than 100％ and 95.43％ of KDRGs for data from clinics. The variance reduction achieved by the KDRG classification was 40.80％ for non-outlier claims from tertiary care hospitals, 51.98％ for general hospitals, 40.89% for hospitals, and 54.99% for clinics. Similar results were obtained from the analyses performed on a subset of the study database. The study results indicated that KDRGs developed for a classification of inpatient care could be used for ambulatory care, although there were areas where the classification should be refined. Its power to predict tile resource utilization showed a potential for its application to measure case mix of providers for monitoring and managing delivery of ambulatory care. The issue concerning the quality of diagnostic information contained in insurance claims remains to be improved, and significance of future studies for other classification systems based on visits or episodes is guaranteed.

• Journal of Chest Surgery
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• v.39 no.2 s.259
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• pp.117-126
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• 2006

Background: The purpose of this study is to describe the characteristics of malpractice claims related to hemopneumothorax and to identify the causes and potential preventability of such claims. Material and Method: A retrospective study was performed by reviewing the records in the Lawnb website and Lx CD-rom: the records on closed malpractice claims involving hemopneumothorax were abstracted from the files available for analysis. The records were reviewed and were analysed to determine the etiology of hemopneumothorax, patient age, results of lawsuit and indemnity payment, underlying diseases, cause of death or complications, and the factors associated with a successful defense. Result: Seven closed claim involving hemopneumothorax were founded in the data for malpractice. Three claims were supreme court decision, one was a high court decision and three claims were district court decision. The most common cause of death was tension pneumothorax. Four of which resulted in indemnity payments. Conclusion: While malpractice claims involving hemopneumothorax were uncommon, they resulted in a high rate and amount of indemnity payments. Claims are more common in pediatric patients. In case of iatrogenic hemopneumothorax, post-procedural X-ray can improve patient outcome and is also associated with decreased indemnity risks. Informed consent is also important.

• Journal of Preventive Medicine and Public Health
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• v.31 no.4 s.63
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• pp.814-827
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• 1998

In this study we analyzed the insurance claims data to investigate the medical care utilization pattern of tuberculosis patients in private sector. We selected the claims of principal or secondary diagnosis with tuberculosis from claims database of National federation of Medical Insurance, from December 1995 to November 1996. Both spell-based analysis and person-based analysis were carried out. In spell-based analysis, type and location of treatment facilities, distribution of diagnoses, number of outpatient/inpatient treatments were analyzed. Additionally in person-based analysis, number of tuberculosis patients, demographic characteristics, number of treatments per person, frequency and pattern of change in source of care were analyzed. The results were as follows 1. The number of treatments with tuberculosis was 863,641 from 1 December 1995 to 30 November 1996. The number of patients was 313.964. 2. Most of tuberculosis patients in private sector were treated in general hospital (45.8%) and clinics(42.2%) 3. About 77.7% of tuberculosis patients who were treated more than two times did not change the source of care. 18,9% of tuberculosis patients changed source of care only once. Even when we limited tuberculosis patient to those who were treated more than five times and whose treatment period were longer than six months, 94.7% of patients did not change source of care at all, or changed treatment facility only once. 4. The probability of change in source of rare was higher in pulmonary tuberculosis, in twenties, and in rural area respectively than other tuberculosis. In conclusion, healer shopping of tuberculosis patients was not serious as expected. However special attention is needed to pulmonary tuberculosis in twenties and rural area.

• International conference on construction engineering and project management
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• 2022.06a
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• pp.1240-1240
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• 2022

Construction projects are fraught with risks from cost or other overruns to accidents along with other issues. This is true whether the relevant organization is an owner, general contractor, CM, specialty-trade contractor, or other entity. When cost issues or other issues confront arise, how should an organization proceed whether attempting to gain additional compensation in terms of cost/other damages or protecting the same against such claims if they do not appear to be warranted? Enter construction cost forensics. This presentation will focus on strategies/techniques with construction cost forensics in these areas in order to be successful. Covered techniques include those to develop and analyze claims including fundamental construction cost analysis techniques. When an unexpected event disrupts a construction project, using sound analytical methods to identify the cause and quantify the extent of the issue will be important for negotiating a fair result or for obtaining a successful outcome in arbitration or litigation. Key examples of uncovering issues via construction cost forensics will be covered in this presentation.

• Health Policy and Management
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• v.34 no.2
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• pp.163-177
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• 2024

Background: This study aims to examine changes in fraudulent claim counts and total reimbursements before and after enhancements in counterfeit claim controls and monitoring of provider claim patterns under the "Proactive self-audit pilot program of fraudulent claims." Methods: This study used the claims data and hospital information (July 2021-February 2022) of the Health Insurance Review and Assessment Service. The data was collected from 1,129 hospitals assigned to the pilot program, selected from the providers who filed a claim for reimbursement for intravenous injections. Paired and independent t-tests, along with regression analysis, were utilized to analyze changing patterns and factors influencing claim behaviors. Results: This program led to a reduction in the number of fraudulent claims and the total amount of reimbursements across all levels of hospitals in the experimental groups (except for physicians below 40 years old). In the control group, general hospitals and hospitals demonstrated some significant decreases based on the duration since opening, while clinics showed significant reductions in specified subjects. Additionally, a notable increase was observed among male physicians over the age of 50 years. Overall, claims and reimbursements significantly declined after the intervention. Furthermore, a positive correlation was found between hospital opening duration and claim numbers, suggesting longer-established hospitals were more likely to file claims. Conclusion: The results indicate that the pilot program successfully encouraged providers to autonomously minimize fraudulent claims. Therefore, it is advised to extend further support, including promotional activities, training, seminars, and continuous monitoring, to nonparticipating hospitals to facilitate independent improvements in their claim practices.

• Proceedings of the Korean Society of Health Policy and Administration Conference
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• 2005.12a
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• pp.361-362
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• 2005

• Proceedings of the Korean Institute Of Construction Engineering and Management
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• autumn
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• pp.341-344
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• 2002

Claims are on an increasing trend in the domestic construction field with changes of negative thought about them. But there are still many factors of causing disputes Potentially due to old customs that an owner is predominant over a contractor. Unless these factors are solved, it is obvious that many disputes will occur henceforward. This study derives claim factors that must be solved first of all through analyzing how claim factors influence construction management factors such as time, cost, quality, and presents countermeasures that may prevent these claims.

• Journal of Korean Medical classics
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• v.27 no.3
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• pp.33-46
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• 2014

Objectives : Sosihotang is a typical prescription in Sang Han Lun. And the alternate chills and fever is a Sosihotang's typical symptom. Therefore I will study of how the syndrome of Sosihotang's alternate chills and fever caused. Methods : Examine the claims of the syndrome of Sosihotang's alternate chills and fever in Sang Han Lun. The scholar's claims are not all same. Thus, I analysis the claims of many scholars. Results : The syndrome of Sosihotang has two mechanisms. The move of defensive Gi(衛氣) can explain the occurrence of alternate chills and fever. If the defense Gi enter inside the body, it struggle with pathogenic Gi, the fever is occurred. On the contrary to this, if the defense Gi exits the body the chills occurs because of the lack of defense Gi. Conclusions : The syndrome of Sosihotang could be taken ill by tranmission or direct attack of exogenous pathogenic factors(直中). Symptoms chills and fever occurs due to the entrance and exit of defensive Gi.

• Journal of Fashion Business
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• v.26 no.6
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• pp.82-93
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• 2022

Sustainability is a significant change that fashion industry has undergone. Marketers and brands are looking for guidance in green advertising to most effectively motivate consumers to purchase sustainable fashion products. This study aims to reveal environmental and cultural sustainability claims on message credibility and purchase intention regarding product trendiness. We performed mediation and moderation analyses, using a 2 (sustainability message: environmental and cultural) × 2 (product design: classic vs. trendy) between-subjects experimental design. The PROCESS MACRO was used for the analysis. Results indicate that environmental claim must appear credible to consumers to motivate them to purchase a product. On the other hand, cultural claim, with and without credibility, affected consumer's purchase intention. Moreover, cultural claim and trendy design together influenced message credibility and purchase intention, showing a moderated mediation effect. The study indicates that brands should broaden their perspective regarding sustainability by considering cultural factors when providing sustainability claims. Environmental claim should be clear and transparent to avoid green skepticism. Also, it is important to focus on product's design aspect: making trendy designs. It is difficult to change consumer behavior based only on sustainability value. Thus, brands must coney their consideration of design trends. Theoretical and managerial implications also are discussed.

• Journal of Distribution Science
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• v.21 no.6
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• pp.51-68
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• 2023

Purpose: This study aims to explore the impact of green products' claim skepticism on green purchase intention and further investigates the moderating role of environmental concern in the relationship. This study, by drawing the persuasion knowledge model expected that ambiguity avoidance penalizes less familiar brands than familiar brands. Further, the present study building on Hofstede's cultural dimension, specifically, uncertainty avoidance, undertook a scenario to understand any difference that exist between uncertainty avoidance cultural groups. This study also investigates gender differences in green claim skepticism and proclivity to purchase green products. Research design, data, and methodology: For analyzing the relationship relevant hypotheses were designed, and R-programming software was used. To test the hypotheses two independent sample t-test and regression analysis were carried out. Results: The results suggest that consumers' skepticism toward green claims influenced the intention to purchase eco-friendly products. The study finding also confirms the effect is moderated by environmental concern. Also, the findings of two scenarios reveal that consumers in high uncertainty avoidance culture exhibited a greater level of skepticism for green print advertising and green packaging claims when the brand in the advertising and packaging was unfamiliar than when it was familiar. Conclusions: To alter the negative effect of skepticism the consumer should believe the environmental claims are valid so that they can contribute to solving sustainability issues.