• Journal of the Korea Safety Management & Science
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• v.12 no.3
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• pp.257-262
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• 2010

The study investigates the various Acceptance Control Charts (ACCs) based on the factors that include process independence, data weighting scheme, subgrouping, and use of control charts. USL - LSL > $6{\sigma}$ that used in the good condition processes in the ACCs are designed by considering user's perspective, producer's perspective and both perspectives. ACCs developed from the research is efficiently applied by using the simple control limit unified with APL (Acceptable Process Level), RLP (Rejectable Process Level), Type I Error $\alpha$, and Type II Error $\beta$. Sampling interval of subgroup examines i.i.d. (Identically and Independent Distributed) or auto-correlated processes. Three types of weight schemes according to the reliability of data include Shewhart, Moving Average(MA) and Exponentially Weighted Moving Average (EWMA) which are considered when designing ACCs. Two types of control charts by the purpose of improvement are also presented. Overall, $\alpha$, $\beta$ and APL for nonconforming proportion and RPL of claim proportion can be designed by practioners who emphasize productivity and claim defense cost.

• Korean Journal of Logic
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• v.11 no.2
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• pp.93-125
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• 2008

The radical probabilitists deny that propositions represent experience. However, since the impact of experience should be propagated through our belief system and be communicated with other agents, they should find some alternative protocols which can represent the impact of experience. The useful protocol which the radical probabilistists suggest is the Bayes factors. It is because Bayes factors factor out the impact of the prior probabilities and satisfy the requirement of commutativity. My main challenge to the radical probabilitists is that there is another useful protocol, q(E|$N_p$) which also factors out the impact of the prior probabilities and satisfies the requirement of commutativity. Moreover I claim that q(E|$N_p$) has a pragmatic virtue which the Bayes factors have not.

• Journal of Korean society of Dental Hygiene
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• v.11 no.3
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• pp.325-341
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• 2011

Objectives : This research has investigated the reality of the education of the claim and the degree of the education for the claimed of the dentistry recuperation organization in the Daejeon and Chuncheong are for the improvement of the problem in the medical expenses. Methods : It use as a basic data for the vitalizations of the education and performed the survey in the dentistry recuperation organization in the Daejeon and ChungCheong Nam BukDo which are registered in the evaluating organization for judging the health insurance in the present May 2010, and concluded just like the below. Results : 1. The education of the claim in the requirer in the dentistry recuperation organization, and the education of the claim was especially lacking when the dentist was studying in the university, and the dental hygienist had the similar educational experience in the school and the clinic (p<0.05) 2. Most of the requirer in the dental recuperation organization was hoping to get the education related to the claim work, but the dentist and the nurse's aid was relatively low (p<0.05) 3. For fixing the error of the claim, the participation and the extension of the judging standard of the insurance was the highest among the university subordinate dental hospital/dental hospital, but the health center was relatively low (p<0.05). 4. The dentist feels the economic burden in employing the special employee because the raising of the special judging people, compared to others, but the staffs such as the dental hygienist preferred it as one of ways to fix the error of the claim of the dental insurance (p<0.05) 5. Both dentists and the dental hygienist said proper time to teach the insurance was all needed in the school, and the clinic, but other workers relatively believed it should be held in the clinic (p<0.05). 6. The important factors to decide the participation of the lecture was in order of the contents of the lecture, the place of the lecture, the amount for the lecture, the superintendent of the lecture, whether it has gone through the educational score, and whether it has passed the conserving educational score was relatively less important in the university subordinate dentist/dentist, but the medical center was very effective as 4.50 (p<0.05) 7. Health Insurance Review and assessment service was very high as the managing department for supplying the lecture and the information, 70.5%, and the next was the Korean Dental Association/ Korean dental hygiene association, but dentists were preferring the association to manage in than the Health Insurance Review and assessment service to manage (p<0.05) 8. In preferring lecture for the inquiring the insurance, periodontal surgery was the highest as 4.51, the diagnosis standard for injection was high in the university subordinate hospital/dentists, and the more the year of the insurance inquiry, the less the doctor who was hoping for the lecture about the basic treatment. Conclusions : Taken together, it is decided that the inquiry education about the medical expense in the dentist, so the consistent and systematic education should be held to the related people, and from this, it is thought to reduce the problem of the inquiry of the medical expenses by fostering the knowledge and supplying the information which are related to the inquiry of the dentists.

• 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 Korean Public Health Nursing
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• v.28 no.3
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• pp.522-535
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• 2014

Purpose: This study was constructed in order to examine factors that influence work-related musculoskeletal disease (WMSD) approvals and current status according to the company size. Method: This is a descriptive study that utilized Industrial Accident Compensation Claim Data. Workplaces with over 35,811 workers derived from the 2012 claim data, which comprised approximately 91.5%, were selected for this study. Then workplaces were divided into three groups according to the number of workers: less than 5, 5~299, and 300 and over. Results: Since 2008, the number of small sized workplaces has increased. The 2012 data showed that 32.5% of workers at small sized workplace had WMSD. However, workplaces with 5~299 workers showed WMSD approval rate of 60%. Of note most WMSD approved workers were employed by manufacturing and construction companies, regardless of the workplace size. Most of them were engaged in elementary tasks. The days of medical treatment at OPD and IPD were most prevalent among workers at the largest workplaces. Conclusions: It is certain from this study that WMSD has been polarized by the company size. More policy attention should be paid to the WMSD status of workers at small sized workplaces which usually do not have their own health office.

• The Journal of the Korean life insurance medical association
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• v.27 no.2
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• pp.96-106
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• 2008

Herniate disc disease is one of the biggest problem in claim of insurance as well as in medical. Herniate disc disease have recently increased, and it is ranked 8th in claim reasons recently. As an underwriter and physical therapist, I want to study interrelationship of insurance and disc disease. I think it is necessary to know about knowledge of medical, so this study is given some space to structure of spine, cause of herniated disc disease, role of disc, methods of classification of disable (McBride method and AMA method), and spine disability stage. disc surgery is divided laparoscope disc surgery and spine surgery. I analysis it some factors- gender, age, occupation, re-surgery, and state of after surgery - through searching medical papers. I suggest below conclusion to underwriter because it can be useful to make questionnaire, and underwriter can expect prognosis. conclusion The negative factors of disc surgery (compare to other cases) were as follows: 1. endoscope disc surgery: $20{\sim}40year$ old man, hospitalization period more than 5 days. 2. spine surgery: $45{\sim}70year$ old woman, hospitalization period more than 15 days. 3. re-surgery experience: exist 4. working condition: a person who draws a small income, non-regular worker, working period is less than 1 year. 5. method of surgery: pedicle screw fixation. spine fusion surgery, artificial disc surgery. 6. post surgery condition: appearance of muscle weakness, paralysis, reference pain, lordosis, kyphosis, and complication. smoker or take a drink.

• 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.

• Health Policy and Management
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• v.16 no.2
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• pp.49-76
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• 2006

The aim of this study was to explore the effects of a computerized review program which was introduced in August 1, 2003, using claims data for acute respiratory infection related diseases. National Health Insurance (NHI) claims data on respiratory infection related diseases before and after the introduction, with six month intervals respectively, were used for the analysis. Clinic was the unit of observation, and clinics with only one physician whose specialty was internal medicine, pediatrics, otorhinolaryngology and family medicine and clinics with a general practitioner were selected. The final sample had 7,637 clinics in total. Indices used to measure practice pattern was prescription rates of antibiotics, prescription rates of injection drug per visit, treatment costs per claim, and total costs per claim. Changes in the number of claims for major disease categories and upcoding index for disease categories were used to measure claiming behavior. Data were analysed using descriptive analysis, t-test for indices changes before and after the introduction, analysis of variance (ANOVA) for practice pattern change for major disease categories, and multiple regression analysis to identify whether new system influenced on provider' practice patterns or not. Prescription of antibiotics, prescription rates of injection drug, treatment costs per claim, and total costs per claim decreased significantly. Results from multiple regression analysis showed that a computerized review system had effects on all the indices measuring behavior. Introduction of the new system had the spillover effects on the provider's behavior in the related disease categories in addition to the effects in the target diseases, but the magnitude of the effects were bigger among the target diseases. Rates of claims for computerized review over total claims for respiratory diseases significantly decreased after the introduction of a computerized review system and rates of claims for non target diseases increased, which was also statistically significant. Distribution of the number of claims by disease categories after the introduction of a computerized review system changed so as to increase the costs per claims. Analysis of upcoding index showed index for 'other acute lower respiratory infection (J20-22)', which was included in the review target, decreased and 'otitis media (H65, H66)', which was not included in the review target, increase. Factors affecting provider's practice patterns should be taken into consideration when policies on claims review method and behavior changes. It is critical to include strategies to decrease the variations among providers.

• Journal of the Korea Convergence Society
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• v.12 no.10
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• pp.137-144
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• 2021

The purpose of this study is to analyze the factors affecting the education experience, education needs, and knowledge level of calculation criteria for dental workers. It was conducted on dental workers in Daegu and Gyeongbuk province and an online survey was conducted using Google Survey. We used frequency analysis, crossover analysis, and ANOVA analysis method to find out general characteristic, education experience, education needs, and knowledge level according to education experience and education needs of candidates. As a result of in the knowledge level survey of dental health insurance, there were high rates of incorrect answers to the calculation criteria when the claim program automatically processes it or notifies you through an error window. The level of knowledge of candidates who are experienced, on a claim, and with experience in dental insurance training in the last six months was high. In conclusion, it seems that accurate and correct insurance claims are possible when the dental workers are familiar with the calculation criteria changed through regular dental health insurance education. We look forward to this study providing basic data in preparation of education system for professional dental insurance claims for dental workers.

• English Language & Literature Teaching
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• v.12 no.2
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• pp.19-40
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• 2006

This paper deals with a part-specific analysis of grammatical errors in the production of the English passive in writing. The purpose of the study is dual: to explore common error types in forming the passive; and to provide plausible sources of the errors, with special attention to the role of the native language. To this end, this study obtained a large amount of data from Korean EFL university students using an essay writing task. The results show that in forming the passive sentence, errors were made in various ways and that the most common problem was the formation of the be-auxiliary, in particular, the proper use of tense and S-V agreement. Another important finding was that the global errors found in this study were not necessarily those with the greatest frequency. Also corroborated was the general claim that many factors work together to account for errors. In many cases, interlingual and intralingual factors were shown to interact with each other to explain the passive errors made by Korean students. On the basis of the results, suggestions are made for effective and well-formed use of the passive sentence.