• 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.

• Journal of Chest Surgery
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• v.49 no.sup1
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• pp.37-43
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• 2016

Background: While demand for cardiovascular surgery is expected to increase gradually along with the rapid increase in cardiovascular diseases with respect to the aging population, the supply of thoracic and cardiovascular surgeons has been continuously decreasing over the past 10 years. Consequently, this study aims to achieve guidance in establishing health care policy by analyzing the supply and demand for cardiovascular surgeries in the medical service area of Korea. Methods: After investigating the actual number of cardiovascular surgeries performed using the National Health Insurance claim data of the Health Insurance Review and Assessment Service, as well as drawing from national statistics concerning the elderly population aged 65 and over, this study estimated the number of future cardiovascular surgeries by using a cell-based model. To be able to analyze the supply and demand of surgeons, the recent status of new surgeons specializing in thoracic and cardiovascular surgeries and the ratio of their subspecialties in cardiovascular surgeries were investigated. Then, while taking three different scenarios into account, the number of cardiovascular surgeons expected be working in 5-year periods was projected. Results: The number of cardiovascular surgeries, which was recorded at 10,581 cases in 2014, is predicted to increase consistently to reach a demand of 15,501 cases in 2040-an increase of 46.5%. There was a total of 245 cardiovascular surgeons at work in 2014. Looking at 5 year spans in the future, the number of surgeons expected to be supplied in 2040 is 184, to retire is 249, and expected to be working is 309-an increase of -24.9%, 1.6%, and 26.1%, respectively compared to those in 2014. This forecasts a demand-supply imbalance in every scenario. Conclusion: Cardiovascular surgeons are the most central resource in the medical service of highly specialized cardiovascular surgeries, and fostering the surgeons requires much time, effort, and resources; therefore, by analyzing the various factors affecting the supply of cardiovascular surgeons, an active intervention of policies can be prescribed for the areas that have failed to meet the appropriate market distributions.

• Journal of Preventive Medicine and Public Health
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• v.24 no.4 s.36
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• pp.485-495
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• 1991

This study examined the effects of referral requirements for insurance patients which have been enforced since July 1, 1989 when medical insurance coverage was extended to the whole population except beneficiaries of medical assistance program. The requirements are mainly aimed at discouraging the use of tertiary care hospitals by imposing restrictions on the patient's choice of a medical service facility. The expectation is that such change in the pattern of medical care utilization would produce several desirable effects including increased efficiency in patient care and balanced development of various types of medical service facilities. In this study, these effects were assessed by the change in the number of out-patient visits and bed-days per illness episode and the share of each type of facility in the volume of services and the amount of expenditures after the implementation of the new referral system. The data for analysis were obtained from the claims to the insurance for government and school employees. The sample was drawn from the claims for the patients treated during the first six months of 1989, prior to the enforcement of referral requirements, and those of the patients treated during the first six months of 1990, after the enforcement. The 1989 sample included 299,824 claims (3.6% of total) and the 1990 sample included 332,131 (3.7% of total). The data were processed to make the unit of analysis an illness episode instead of an insurance claim. The facilities and types of care utilized for a given illness episode are defined to make up the pathway of medical care utilization. This pathway was conceived of as a Markov Chain process for further analysis. The conclusion emerged from the analysis is that the enforcement of referral requirements resulted in less use of tertiary care hospitals, and thereby decreased the volume of services and the amount of insurance expenses per illness episode. However, there are a few points that have to be taken into account in relation to the conclusion. The new referral system is likely to increase the use of medical services not covered by insurance, so that its impact on national health expenditures would be different from that on insurance expenditures. The extension of insurance coverage must have inereased patient load for all types of medical service organizations, and this increase may be partly responsible for producing the effects attributed to the new referral system. For example, excessive patient load for tertiary care hospitals may lead to the transfer of their patients to other types of facilities. Another point is that the data for this study correspond to very early phase of the new system. But both patients and medical care providers would adapt themselves to the new system to avoid or overcome its disadvantages for them, so as that its effects could change over time. Therefore, it is still necessary to closely monitor the impact of the referral requirements.

• Journal of Digital Convergence
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• v.11 no.10
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• pp.593-608
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• 2013

According to increasing number of injury claims, the challenge is reducing investigation of cases of injuries by selecting them more delicately, while also increasing the redemption rates and the amount of restitution. In this regards, we developed the fraud detection model for injury claims of self-employed insured by using decision tree after collecting medical claim data from 2006 to 2011 of the National Health Insurance in Korea. As a result of this model, subject types were classified into 18 types. If applying these types to the actual survey compared with if not applying, the redumption collecting rate will be increasing by 12.8%. Also, the effectiveness of this model will be maximize when the number of claims handlers considering their survey volume and management plans are examined thoroughly.

• Proceedings of the Korea Water Resources Association Conference
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• 2019.05a
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• pp.193-193
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• 2019

기후변화로 인한 거대 자연재해 발생의 위험이 지속적으로 증가하고 있으며, 국외의 경우 주요정부기관, 보험사 및 연구기관 중심으로 자연재해 피해예측 모델을 개발하여 사용하고 있다. 침수사고 인한 피해는 건물은 물론이고 가재도구, 재고자산, 기계시설 등의 내용물에서도 발생하며, 건축물 신축단가 등을 이용해 비교적 쉽게 자산가치를 산정할 수 있는 건물구조물과 다르게, 건물내용물의 자산가치는 시설물의 업종, 용도, 사용자 특성 등에 따라 변동성이 큰 특징이 있다. 내용물의 피해액 추정을 위해 자연재해 피해예측 모델은 건물 구조물과 내용물 가치의 비율인 CSVR(Contents to Structure Value Ratio)을 사용하며, CSVR은 시설물 용도에 따른 자산가치평가 통계를 이용해 산정할 수 있다. 충분한 자산가치평가 DB를 확보할 경우 CSVR의 정확도 확보가 가능할 것이며, 이를 위해 국내에서는 민간보험사의 재물보험 계약 4만여건의 건물, 내용물 보험가입금액을 행정안전부 도로명전자지도에서 분류하는 건물 용도에 따라 분석한 연구결과가 있다. 하지만, 일반적으로 보험가입단계에서 대략적으로 추정하는 보험가입금액과 실제 자산의 가치는 차이가 있을 수 있지만, 보험가입물건의 실제 자산가치는 일부만 DB화 되어 있는 단점이 있다. 본 연구에서는 사고 발생 후 작성되는 손해사정보고서에서 평가한 정확한 자산가치 DB를 수집하여, 보험가입금액을 기준으로 산정한 CSVR의 결과와 비교하였다. 손해사정보고서에서 평가한 실제 자산가치를 기준으로 분석한 CSVR과 보험가입금액을 기준으로 산정한 CSVR은, 업종에 따라 유사하거나 큰 차이를 보이는 경우도 있었으며, 침수로 인한 정확한 피해액 추정을 위해서는 보다 양질의 DB확보를 통한 CSVR의 정확도 확보가 필요한 것으로 분석되었다.

• THE INTERNATIONAL COMMERCE & LAW REVIEW
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• v.55
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• pp.209-240
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• 2012

Since the age of Lord Mansfield, who laid the foundation of the modern English insurance contract law in the second part of the 18th century, English insurance law has developed a unique rule of warranty. Lord Mansfield adopted very different approach and afforded such a strict legal character to insurance warranty, because the promise, given by the insured, played an important role for the insurer to assess the scope of the risk insured at that time. It is still important that the insured keep his promises strictly to the insurer under the insurance contract, but legal environments have changed dramatically since the times of Lord Mansfield. English Law Commission proposed some proposals for reforming the warranty regime to reflect the changes of legal environment in CP 2007. This article is, therefore, designed to examine the proposals and consider their legal and practical implications. The proposals of Law Commission is summarized as following. First, in CP 2007, Law Commission made two principal proposals for reform of the law on warranty. The first is that the insurer should not be entitled to rely on a breach of warranty unless the insured has been provided with a witten statement of what they have undertaken under warranty. The second is that the insurer should not be entitled to reject a claim on the ground that the insured has breached a warranty unless there was a causal connection between the breach and the loss. Secondly, for consumer insurance, the rule requiring a causal connection would be mandatory, whereas for business insurance, it would be possible for the parties to agree on the effect a breach of warranty should have, provided they use clear language to express their intentions. Thirdly, where the insured contracted on the insurer's written standard terms of business, some statutory controls would be afforded to the contract to ensure that the cover was not substantially different from what the insured reasonably expected. Finally, Law Commission propose that a breach of warranty give the insurer the right to terminate the contract, rather than automatically discharging it from liability, but (unless otherwise agreed) only if the breach has sufficiently serious consequences to justify termination under the general law of contract. Having evaluated the proposals of the Law Commission and considered their legal and practical implications, it is quite clear that the proposed rule interfere with freedom of contract and create legal uncertainty. But change can not made without any victims, so Law Commission's attempt to change severe and injust aspects of the warranty regime would be very welcomed and respected.

• 한국노년학
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• v.31 no.2
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• pp.259-276
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• 2011

If frail elderly could use home care services adequately, quality of their life might improve and their costs of service would be decreased. The purpose of this study is to examine the factors on institutionalization of elderly using home care services in Korean long-term care insurance system. This study used the data of '2009 satisfaction survey of Korean long-term care system'. The survey proceeded using sampling data by region, level of long-term care need, and insurance type among beneficiaries from August 2009 to September 2010. The onset dates of institutionalization of 1,230 participants were ascertained from long-term care insurance claim data. This study calculated hazard ratio through Cox Proportional Hazard Model. The results showed that if elderly using home care services suffer a fracture, the hazard ratio of institutionalization is higher significantly. Although not significant, if older persons have more items of damaged cognitive functions, the hazard ratio of institutionalization is higher. The results have policy implications to supplement of home care service system and postpone institutionalization of elderly.

• Quality Improvement in Health Care
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• v.17 no.1
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• pp.69-78
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• 2011

Objectives : The purpose of this study was to determine whether the published AMI report card could reduce in-patient mortality, 7-day after discharge mortality, and length of stay (LOS). Methods : Interrupted time-series intervention analysis was used to evaluate the impact of the report card for AMI care quality in November 2005 in terms of risk-adjusted in-patient mortality, risk-adjusted 7-day after discharge mortality, and DRGs case-mix LOS using the claim data of Health Insurance Review and Assessment Service. Results : Public disclosure of AMI care quality decreased risk-adjusted in-patient mortality and DRGs case-mix LOS by 0.00050% per month and 0.042 days per month respectively, however there was no effect on risk-adjusted 7-day after discharge mortality. Patterns of effect of public disclosure on AMI outcomes were a fluctuating pattern on risk-adjusted mortalities and a pulse impact for 1 month on DRGs case-mix LOS. Conclusions : We found the public disclosure of AMI care quality had decreasing effects on risk-adjusted in-patient mortality and DRGs case-mix LOS, but the size of the effect was marginal.

• The Korean Journal of Applied Statistics
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• v.13 no.2
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• pp.247-263
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• 2000

Natural catastrophe is defined as all damages caused by natural phenomenon such as typhoon, flood, inundation, windstorm, tidal wave, tremendous snowfall, drought,earthquake and to on It is classified at a huge hazard because of the large severity ofdamage In Korea, Fire Insurance policy includet the coverage clauses and rates of naturalcatastrophe like'Flood , Inundation Coverage Clause'and'Earthquake Coverage Clause'These clauses and rates do not reflect accurate risk of flood, inundation and earthauakein Korea. because those are tariff from other countries Hence, we determine the claimsize distributions and the rates for typhoon coverage and flood-inundation coverage byusing statistical methods which have not been used so far in Korean non-life insurance,and calculate appropriate premium for policyholder's interest

• Convergence Security Journal
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• v.16 no.1
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• pp.23-32
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• 2016

The more a society becomes complicated and diversified along with the economic development, the more diverse l earning types the educational activities had beyond the existing educational approaches to cope with the complicated and diversified society. In particular, field studies and opportunity to use the dangerous educational appliances have been increasing in order to cope with the desires of education consumers requiring diversity and the individuality of students has been strengthened. In accordance with the trends above, the school accidents have been gradually increasing in recent days. Thus, this paper aims to propose the suggestions to teachers in real education fields by investigating the problems in compensation system of School Safety and Insurance Association against which the victim s of any school safety accidents firstly claim for the damages, the problems in the present system of the Association and how to improve the system in terms of the payment scope of the Association.