• Title/Summary/Keyword: Medical Insurance

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Various underwriting methods through case audit (증례점검 사례를 통한 다양한 언더라이팅 접근 방향 모색)

  • Choi, So-Yung
    • The Journal of the Korean life insurance medical association
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    • v.27 no.1
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    • pp.18-20
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    • 2008

  • I have taught various case audit underwriting methods to underwriters for many years. Underwriting requires specialized medical knowledge and experience of comprehensive individual risk analysis. Decisions in individualized underwriting depend on the insurance company's management philosophy and vision, marketing strategies, culture, product line etc. They also depend on the information acquired through proposal forms, inspection reports, laboratory results and disclosures. Underwriters match this acquired information to each insurance product, search appropriate medical resources, assess the probabilities of future claims, and decide what, if any, further medical information should be gathered. Sources include doctors' reports, medical records, biopsies, blood and urine tests, CT, MRI, Holter monitoring, sonography etc. Insurance medical directors help and teach underwriters to analyze individual medical risks and make effective.

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Imbalance in Cardiovascular Surgery Medical Service Use Between Regions

  • Kim, Myunghwa;Yoon, Seok-Jun;Choi, Ji Suk;Kim, Myo Jeong;Sim, Sung Bo;Lee, Kun Sei;Chee, Hyun Keun;Park, Nam Hee;Park, Choon Seon
    • Journal of Chest Surgery
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    • v.49 no.sup1
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    • pp.14-19
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    • 2016

  • Background: This study uses the relevance index to understand the condition of regional medical service use for cardiovascular surgery and to identify the medical service use imbalance between regions. Methods: This study calculated the relevance index of 16 metropolitan cities and provinces using resident registration address data from the Ministry of Government Administration and Home Affairs and the 2010-2014 health insurance, medical care assistance, and medical benefits claims data from the Health Insurance Review and Assessment Service. We identified developments over the 5-year time period and analyzed the level of regional imbalance regarding cardiovascular surgery through the relative comparison of relevance indexes between cardiovascular and other types of surgery. Results: The relevance index was high in large cities such as Seoul, Daegu, and Gwangju, but low in regions that were geographically far from the capital area, such as the Gangwon and Jeju areas. Relevance indexes also fell as the years passed. Cardiovascular surgery has a relatively low relevance index compared to key types of surgery of other fields, such as neurosurgery and colorectal surgery. Conclusion: This study identified medical service use imbalance between regions for cardiovascular surgery. Results of this study demonstrate the need for political intervention to enhance the accessibility of necessary special treatment, such as cardiovascular surgery.

  • https://doi.org/10.5090/kjtcs.2016.49.S1.S14 인용 PDF KSCI

The Legal Base and Validity of Reviewing Medical Expenses in the Health Insurance (건강보험 진료비심사의 법적 근거와 효력)

  • Kim, Un-Mook
    • The Korean Society of Law and Medicine
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    • v.8 no.1
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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.

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Trends of cardiac valve surgery in life insurance ('09~'11) (보험가입자 심장판막 수술 변화 추이분석 ('09~'11))

  • Park, Yoojung;Moon, Kitae;Kim, Youngeun
    • The Journal of the Korean life insurance medical association
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    • v.32 no.2
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    • pp.28-32
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    • 2013

  • We studied trends of cardiac valve surgery using insurance data. 368 persons were included our study. We studied whether there are frauds or not. Only 4 cases were done at less than 1year from an insurance contract. We reviewed medical records of all persons. We could find the type of valve disease in 211 cases. The findings are atrial valve 40.1%, mitral valve 34.6% and others 25.3%. When we divided by materials of surgery, mechanical valves were used in 68.8% of men and 70.6% of woman. The main causes of valve disease were infection(55.1%). And degenerative valve disease 32% and congenital valve disease were 13%. We cannot find definite evidence of insurance frauds in the cardiac valve surgery. But there are some limitation in data analysis.

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