• Journal of Korean Academy of Fundamentals of Nursing
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• v.10 no.3
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• pp.300-306
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• 2003

Purpose: This study was done to help provide patients with information on medical insurance cost through medical insurance education for nurses, to increase effective management, check on omissions in treatment and appropriateness and accuracy of fees, and to contribute to the economic growth of hospital by providing nurses with necessary knowledge about medical insurance cost. Method: The participants in this study were clinical nurses in general hospitals. The study instrument was a questionnaire developed by the researcher through reference to data for medical insurance education. The data were analyzed with percentages, means, ANOVA, and Duncan method using SPSS PC+10. Result: The results on knowledge of medical insurance according to general characteristics of the nurses showed that there were significant differences according to age: (p=.0036) highest level of education (p=.0007), position (p=.0010) and place where education on medical insurance was received (p=.0093). Conclusion: Continuous in-service education for clinical nurses is reflected in increased knowledge about medical insurance costs but special attention needs to be given to younger nurses and nurses with less education, as well as staff nurses, and those nurses who only received education on medical insurance during their schooling. Accordingly, in-service education is necessary for nurses at the time of orientation so that they have knowledge on standards for recuperation allowance, guidelines to calculate material costs, and guidelines to calculate drug rates. In addition, as medical insurance cost frequently change, all nurses need continuous in-service education.

• The Journal of the Korean life insurance medical association
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• v.2 no.1
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• pp.65-74
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• 1985

• The Journal of the Korean life insurance medical association
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• v.19
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• pp.123-129
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• 2000

• The Korean Society of Law and Medicine
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• v.8 no.2
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• pp.69-118
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• 2007

In providing general medical treatments, the medical service contract between the patient and the doctor is the mutually responsible onerous contract. However, the nature of the mutually assumed contract standings of the patient and the doctor has been changing since the implementation of the national health insurance program. For instance, besides the cases of beyond excessive medical charges and medical negligence, if the doctor charged for his/her medical treatments violating the post-treatment/nursing cover criteria, the overpaid medical charge, regardless of being collected with the patient's consent, has to be refunded back to the patient. Medically needed aspects, treatment results, and unfair benefits favoring the patient are not at all taken into consideration in the health insurance scheme. This makes it easier for patients to get refunds for their share of the medical payments by involving the Health Insurance Review & Assessment Service or the National Health Insurance Corporation, without engaging in civil law suits (for reimbursement claim) against doctors. In other words, the doctor's responsibility to provide medical treatments and the patient's responsibility to pay for the medical treatment provided within the contractual realm are being demolished by the administrational arbitration of the National Health Insurance system. The basic rights of medical service providers, and the patient's right to choose are as important constitutional rights, as the National Health Insurance program, which is essential in the social welfare system. Furthermore, the development of the medical fields should not be prevented by the National Health Insurance system. If the medical treatment services can be divided into necessary treatments, general treatments, and high quality treatments, the National Health Insurance is supposed to guarantee the necessary and general treatments to provide medical treatments equally to all the insured with limited financial resources. However, for the high quality treatments, it is recommended that they should not be interfered by the National Health Insurance system, and that they should be left to the private contract between the patient and the doctor.

• Health Policy and Management
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• v.33 no.2
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• pp.166-172
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• 2023

Background: To improve the support low-income individuals' medical expenses, it is necessary to think about ways to enhance the Catastrophic Health Expenditure Support Program. This study proposes expanding support criteria and changing the income standard. Methods: This study conducted simulations using national data from the National Health Insurance Service. Simulations performed for people who have used health services (n=172,764) in 2022 to confirm the Catastrophic Health Expenditure Support Program's size based on changes to the subject selection criteria. Results: As a result of the simulation with expanded criteria, the expected budget was estimated to increase between Korean won (KRW) 13.2 (11.5%) and 138.6 billion (37.4%), and the number of recipients increased between 41,979 (48.9%) and 150,317 (76.1%). The results of the simulation for the change in income criteria (applied to health insurance levels below the 50th percentile) estimated the expected budget to increase between KRW -8.9 (-7.8%) and 55.6 billion (15.0%) and the number of recipients to increase between -8,704 (-10.1%) and 41,693 (21.1%) compared to the current standard. Conclusion: The 2023 Catastrophic Health Expenditure Support Program's criteria were expanded as per the 20th Presidential Office's national agenda to alleviate the burden of medical expenses on the low-income class. In addition, The Catastrophic Health Expenditure Support Program needs to be integrated with other medical expense support policies in the mid- to long-term, and a foundation must be prepared to ensure the consistency of each system.

• Journal of Korean society of Dental Hygiene
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• v.6 no.3
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• pp.243-261
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• 2006

Priority setting in national health insurances in major advanced countries and the nation was investigated to draw the criteria for priority setting and suggest the most rational criteria for dental insurance so as to help secure the efficiency of medicare financing and individual's health right and also elevate medical consumers' satisfaction with health insurance. 1. Priorities in national health insurance are different from country to country, depending on the medical security systems, priority introducing conditions, and social environment, but have many common factors. 2. The priority setting criteria for national health insurance in those countries include the following in common: the efficiency, equity, and cost effect of treatment, emergency of treatment, consumption of expense, efficacy of treatment, patient's receptiveness, patient's demand, severity of disease, and patient's responsibility for the disease. 3. In oral diseases, severe diseases including oral cavity cancer are low in rate, and in-hospital treatments are few. From the above findings, it is suggested that dental insurance should establish discriminative criteria for priority setting by reflecting the aspects of dental diseases and system difference between dental and other health insurances and taking account of efficiency of treatment through prevention, cost effect, prevalence and incidence of generalized diseases, and individual's financing burden.

• The Journal of the Korean life insurance medical association
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• v.26
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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.

• The Korean Society of Law and Medicine
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• v.15 no.1
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• pp.123-164
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• 2014

Under the new system of 'Separation of pharmaceutical prescription and dispensing' in Korea, which was implemented in 2000, physician could not dispense a medicine, and outpatient should have a physician's prescription filled at a drugstore. After pharmacist makes up outpatient's prescription, National Health Insurance Service(NHIS) pay for outpatient's medicine to pharmacist, except an outpatient's own medicine charge. And NHIS only pay for outpatient's prescription fee to physician and, physician doesn't derive profit from dispensing medicine in itself. Nevertheless, if physician writes out a prescription with violation of 'Criteria for the Medical Care Benefits', NHIS clawed back the payment of outpatient's prescription and medicine from the physician or the medical institution which the physician belongs to. In the past, NHIS's confiscation was in accordance with 'the National Health Care Insurance Act, Article 52, Clause 1'. But, since 2006 when the Supreme Court declared that there was no legal basis on the NHIS's confiscation of outpatient's medicine payment, NHIS had put in a claim for illegal prescriptions on the basis 'the Korean Civil law, Article 750(tort)'. So, Many medical institutions filed civil actions against NHIS. The key point of this actions was whether the issuing outpatient prescriptions with violations of Criteria for the Medical Care Benefits constitute of the law of tort. On this point, the first trial and the second trial took different position. Finally the Supreme Court acknowledged the constitution of the law of tort in 2013. In this paper, the author will review critically the decision of the Supreme Court, and consider the relativeness between the legal effect of Criteria for the Medical Care Benefits and the constitution of the issuing outpatient prescriptions with violations of Criteria for the Medical Care Benefits as the law of tort.

• The Journal of the Korean life insurance medical association
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• v.32 no.2
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• pp.33-38
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• 2013

Coronary artery diseases are very important agenda in the insurance medicine. Insurance medicine is defined as using medical knowledge for insurance administration such as underwriting, claims, and customer satisfaction. This review article contains review of coronary artery disease in terms of insurance medicine. Estimation of extra-risks for acute myocardial infarction are MR of 349% and EDR of 41‰. In medical underwriting, individual life applicants can be assessed by Framingham's CHD risk assessment model. In claims, medical claims review is a useful method of consulting for claims staffs. Several diagnostic criteria of acute myocardial infarction are introduced in time. The universal definition of myocardial infarction by ESC/ACCF/WHF was demonstrated the most valuable predictor of 10-year mortality. Contents for State-Of-The-Art of the coronary artery disease are current antithrombotics. There are many novel anti-thrombotic agents such as ticagrelol, dabigatran, rivaroxaban, and pegnivacogin.

• Korea Journal of Hospital Management
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• v.19 no.2
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• pp.1-11
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• 2014

The purpose of this study is to investigate awareness on medical insurance on the caregivers cost for hospital administrative staff and to provide the basic data for realization of legislation. The subjects were caregivers living in Busan, the survey was conducted from February 18 to March 9, 2013, 283 except for 17 copies of non-response and error response among a total of 300 questionnaires were analyzed. As a result, To improve the quality of care services, there were 51.8% of refresher training needs in refresher training items, 72.7% in favor of premiums increases in health insurance details, as for health insurance coverage subjects, patients' income were 32.0%, copayment for caregivers cost was 20.0%, which was 42.3%. Refresher training item, premiums increases, health insurance applied subjects, variables for copayment for care fee were related to medical insurance on the caregivers cost. On legislation on the medical insurance, systematic and standardized criteria should be provided to provide standardized curriculum for caregivers, to relieve patients and guardians of economic burden for caregivers cost and offer the stability of the cost.