• Journal of Preventive Medicine and Public Health
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• v.16 no.1
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• pp.121-127
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• 1983

To identify the changes in professional services pattern after introducing the deligated system of claims review started in 1982, a university hospital under this system was examined. For comparison, claims of the hospital to Federation of Korean Medical Insurance Societies, where this system is not accepted, were reviewed. A total of 600 cases each were studied operated at the Departments of General Surgery & Orthopedic Surgery in 1981 and 1983. The results are summarized as follow: 1. Percentages of hospital charges for basic care was decreased by 10.2% and that for medical service increased by 8.4% in 1983. 2. After the introduction of the deligated review system, percentages of cutting off the claims was decreased by 12.4% for basic care and increased by 3.8% for medical services. 3. Percentage of testing liver function, and the frequency of administering high cost intravenous fluid injection, applicating Robinul as anesthetic premedication were decreased respectively after introducting the deligated services system.

• The Journal of the Korean life insurance medical association
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• v.27 no.1
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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.

• 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.

• The Journal of the Korean dental association
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• v.53 no.2
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• pp.82-95
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• 2015

Background: Interest in medical malpractice claims and accidents is a day-to-day social issue to general public as well as medical personnel. Related laws and regulations already have been established, and institutions based on the laws and regulations also have been founded. However, in our dental community, interest and response to the issue seem insufficient. Methods: We searched four medical literature databases that are mainly cited in the medical community. Keywords including 'dental malpractice claims', 'patient safety' and 'medical accident' were used for the search. Among the selected literatures, we chose specific ones separately whose content is authentic and easily approachable. Results: Medical malpractice claims and accidents tend to increase around the world. As the cost or the difficulty level of surgery increases, the dispute rate also increases, which appears even more apparent in developed countries. Preventive measures to prevent the disputes and accidents are not significantly different. Three critical of them include relationship of doctor with patient, the informed consent and medical record. Conclusion: Tools for accident occurrence or communication improvement have been introduced. All of those cost time and money. However, education or professional request of liability insurance companies, self-education and provision of guidelines can be immediately implemented. To implement those, dentists' promotion at the regional or national level is imperative. rhBMP-2 is widely used at sinus augmentation, alveolar bone defect, and socket preservation.

• The Journal of the Korean life insurance medical association
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• v.27 no.2
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• pp.68-74
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• 2008

Medical verification of cancer diagnosis in insurance claims is a very important procedure in insurance administrations. Claims staffs are in need of medical experts' opinions about claim administration. This procedure is called medical claim review (MCR) and is composed of verification and advice. MCR verification evaluates the insured’s physical condition by medical records and compares it with product coverage. It is divided into assessment of living assurance benefit, verification of cancer, and assessment of the cause of death. Actually cancer verification of MCR is applicable to coding because the risk ratio in product development is usually coded data. There are some confusing neoplastic diseases in assessing the verification of cancer. This article reviews gastrointestinal stromal tumors (GIST) and mucosa-associated lymphoid tissue tumors (MALToma) of the stomach. The second most common group of stromal or mesenchymal neoplasms affecting the gastrointestinal tract is GIST. Nowadays there are many articles about the pathophysiology of GIST. However there are few confirmative theories except molecular cell biology of KIT mutation and some tyrosine kinase. Therefore, coding the GIST, which has previously been classified as an intermediate risk group according to NIH2001 criteria, for cancer verification of MCR is suitable for D37.1; neoplasm of uncertain or unknown behavior of digestive organs and the stomach. The gastrointestinal tract is the predominant site of extranodal non-Hodgkin's lymphomas. B-cell lymphomas of the MALT type, now called extranodal marginal zone B-cell lymphoma of MALT type in the REAL/WHO classification, are the most common primary gastric lymphomas worldwide. Its characteristics are as follows. First, it is different from traditional stomach cancers such as gastric adenocarcinoma. Second, the primary therapy of MALToma is the eradication of H. pylori by antibiotics and the remission rate is over 80%. Third, it has a different clinical course compared to traditional malignant lymphoma. Someone insisted that cancer verification is not possible for the above reasons. However, there have been findings on pathologic mechanism, and according to WHO classification, MALToma is classified into malignant B-cell lymphoma and it must be verified as malignancy in MCR.

• Korea Journal of Hospital Management
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• v.28 no.3
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• pp.47-57
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• 2023

Purpose: Health expenditure and utilization of Korean medicine are increasing every year. Since Chuna Manual Therapy was covered by National Health Insurance in 2019, it is predicted that the usage of Chuna Manual Therapy would be also increasing. However, there are few studies about Chuna Manual Therapy using Korean National Health Insurance claims database. Therefore, we will investigate the utilization trend of outpatient's Chuna Manual Therapy using Korean National Health Insurance database and suggest political implications. Methodology: The Korean National Health Insurance claims database was used to identify outpatient's Chuna Manual Therapy usage spanning 4 years from 2019-2023 and the number of Chuna Manual Therapy claims were approximately 18.61 million. Findings: The number of Chuna Manual Therapy claims and patients, health expenditure of Chuna Manual Therapy have been increasing spanning 4 years among over 65 aged. In the case of female patients, the number of Chuna Manual Therapy claims was more than male patients and health spending related to Chuna Manual Therapy was also higher than male patients. Most patients visited Korean medicine clinics due to musculoskeletal diseases, and most claims were from rural regions. Practical Implication: Since Chuna Manual Therapy was covered by National Health Insurance in 2019, Utilization of Chuna Manual Therapy has been increased overall. In particular, Chuna Manual Therapy is mostly implemented in the elderly, Korean medicine clinics, and local areas, thus policy managers will need to consider this.

• Health Policy and Management
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• v.20 no.4
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• pp.45-57
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• 2010

Background : If different cost efficiency indexes were informed to the same clinic depending on the inclusion or exclusion of pharmacy cost, it may impair the reliability of provider-profiling system. This study aimed to investigate whether the omission of pharmacy cost affects cost-efficiency rankings in medical clinics. Methods : Data for ambulatory care cost at 23,112 medical clinics were collected from the claims database, which was constructed after review by the Health Insurance Review and Assessment Service (HIRA) of Korea in April 2007. We calculated two types of cost efficiency indexes by inclusion or exclusion of pharmacy cost for a medical clinic. The agreement between the decile rankings of the two indexes was also assessed using the weighted kappa statistic of Landis and Koch. Results : When the cost efficiency index for total cost including pharmacy cost was compared with the index for total cost excluding it, the agreement between the two indexes was only 55%. The agreements between the two indexes were relatively low within specialties which have larger pharmacy volume of total cost and lower correlation between total cost with or without pharmacy cost included than the average level of all the specialties. Conclusion : These results suggest that the omission of pharmacy cost may result in contradictory outcomes that may be confusing to a medical institution and may impair the reliability of provider-profiling systems. It is very important to standardize profiling criteria for the reliability of provider profiling system.

• Health Policy and Management
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• v.28 no.4
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• pp.402-410
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• 2018

Background: Monitoring appropriate medication categories can provide early warning of certain disease outbreaks. This study aimed to present a methodology for selecting and monitoring medications relevant to the surveillance of acute respiratory tract infections, such as influenza. Methods: To estimate correlations between acute febrile respiratory tract infection and some medication categories, the cross-correlation coefficient (CCC) was used and established. Two databases were used: real-time prescription trend of antivirals, anti-inflammatory drugs, antibiotics using Drug Utilization Review Program between 2012 and 2015 and physicians' number of encounters with acute febrile respiratory tract infections such as influenza outbreaks using the national level health insurance claims data. The seasonality was also evaluated using the CCC. Results: After selecting six candidate diseases that require extensive monitoring, influenza with highly specific medical treatment according to the health insurance claims data and its medications were chosen as final candidates based on a data-driven approach. Antiviral medications and influenza were significantly correlated. Conclusion: An annual correlation was observed between influenza and antiviral medications, anti-inflammatory drugs. Suitable models should be established for syndromic surveillance of influenza.

• Korean Journal of Clinical Pharmacy
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• v.31 no.4
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• pp.268-277
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• 2021

Background: Most antipsychotic drugs studies have been mainly conducted on side effects, randomized clinical trials, utilization rates, and trends. But there have been few studies on the influencing factors in elderly patients. The purpose of this study was to analyze the influencing factors on the outpatient prescription of antipsychotic drugs in the elderly patients. Methods: Active ingredients of antipsychotic drugs in Korea were selected according to the Korean Pharmaceutical Information Center (KPIC)'s classification. Data source was Korean Health Insurance Review and Assessment Service (HIRA) claims data in 2020 and target patient group was the elderly patient group. We extracted patients who have been prescribed one or more antipsychotic drugs and visited only one medical institution. Data were analyzed using descriptive statistics, chi-square, t-test, negative binomial regression. Results: A number of outpatients were 245,197 and prescriptions were 1,379,092. Most characteristics of patients were 75-85 year's old, female, health insurance type, no disease (dementia, schizophrenia), atypical drugs, cci score (>2) and characteristics of medical institution were neurology in specialty, rural region, general hospitals. Results of regression showed that patient's characteristics and medical center characteristics had significant effect on the outpatient prescription of antipsychotic drugs in the elderly patients. Conclusion: This study suggests that national policy of antipsychotic drugs in the elderly patients, with the consideration of the patients' and medical institutions' characteristics, is needed.

• The Journal of Korean Medicine Ophthalmology and Otolaryngology and Dermatology
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• v.34 no.2
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• pp.21-37
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• 2021

Objectives : Allergic rhinitis(AR) is a common chronic disease that accounts for 10-40% of the world's population. This study aims to analyze the status of claims, prevalence, and medical utilization of allergic rhinitis patients using representative patients sample data. Methods : This study used the National Patients Sample(HIRA-NPS) of the Health Insurance Review and Assessment Service for 7 years(2010-2016). And we defined AR patients as all statements including J30 or a subcategory of J30 as the main disease, using the Korean Standard Classification of Diseases(KCD-7). The trend of AR patients by year was divided into Western medicine(WM) and Korean medicine(KM), and analyzed by subgroup analysis such as inpatient/outpatient, gender, age, insurance type, and care institution. Results : Patients with AR were mainly claimed for first sub diagnosis in WM and major diagnosis in KM, and the number of claims increased about 1.3 times and 1.4 times compared to 2010 in WM and KM, respectively. In addition, the total annual medical expenses in 2016 increased 1.3 times and 1.7 times compared to 2010, respectively. Conclusions : Both WM and KM are showing a steadily increasing trend in medical use due to allergic rhinitis. Further research is needed by considering genetic and environmental factors and individual characteristics, and linking with additional data.