• Health Policy and Management
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• v.27 no.1
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• pp.30-38
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• 2017

Background: This study aims to analyze the behavioral changes of healthcare providers and influencing factors after the reviewer unification of auto insurance medical benefit claims by an independent review agency. Methods: The comparison data were collected from the second half of 2013 and the same period of 2014. The key indicators are the number of admission days, the number of outpatient visits, inpatient ratio, inpatient medical expenses, and outpatient medical expenses. Results: Four indicators (number of admission days, number of outpatient visits, inpatient ratio, and outpatient medical expenses) showed statistically significant drops, while one indicator (inpatient medical expenses) showed no significant change. Conclusion: The reviewer unification of auto insurance medical benefit claims by an independent review agency showed significant reduction in cost and patient days.

• Journal of Korean Academy of Nursing Administration
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• v.9 no.2
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• pp.243-250
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• 2003

Purpose : The purpose of this study was to suggest the number about the projected workforce of Certified Insurance Reviewer Nurses(CIRN) in Korea. Method : The following methods were used for this study: 1) national and international internet data were collected. 2) demand model was used for the prediction of the projected workforce of CIRN. 3) experts in insurance reviewing were contacted to get an opinion and information about the criteria of distribution and scope of CIRNs, 4) we figured out the maximum and minimum number of CIRN Korea needed as followed method, the maximum number was estimated that one CIRN would review 150 cases of Detailed Accounts for Examination and Treatment and the minimum was estimated 200 cases of it. 5) time series regression equation analysis was used for the prediction of number of CIRNs for the year 2003 to 2010. Result: 1) The prediction of CIRNs is as follows, there will be 2,313$\sim$2,827 of CIRN demanded in 2002, 2,500$\sim$3,069 in 2005 and 2,806$\sim$3,466 in 2010. 2) It is really desirable that CIRNs not only work for reviewing the detailed accounts for examination and treatment in hospital but also for inspecting allowance in individual insurance company. Conclusion : It is very desirable that the CIRN advocate the clients' rights because they will work for them satisfactory rather than other hospital experts group. But before settling the system of the CIRN in Korea, there would be its own professional role identity and a code of conduct.

• The Korean Journal of Health Service Management
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• v.11 no.1
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• pp.27-42
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• 2017

Objectives : This study analyzes the characteristics of hospital organization structures, insurance claims reviews and assessment tasks and their effects on hospitals in Pusan. Methods : The data for this study were collected through interview and self-administered surveys in 109 hospitals. The study included only - hospitals with a minimum of 50beds and excluded those providing only dental, psychiatric, or long-term care. Results : The findings of this study state that the number of beds has an influence on the organizitional structure. Conclusions : Hospital managements should seek human resources management(the insurance claims reviewer and evaluator) schemes that take into account the characteristics of the medical institution. In addition, insurance claims review and assessment tasks in hospitals require considerable knowledge and experience, and hospitals should be equipped with staff that have the relevant expertise. Therefore, to further deepen knowledge, comprehensive training should be continuously carried out in order to produce specialists in claims review and assessment.

• Journal of Service Research and Studies
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• v.11 no.1
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• pp.31-44
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• 2021

The net function of the domestic medical insurance system is highly regarded, but due to the problem of incomplete coverage, the public wants to secure coverage through private medical insurance subscription. As a result, the subscription rate of private medical insurance has recently increased, and the billing rate has also increased. As the number of people seeking private medical insurance increased, workers at private medical insurance companies are experiencing increased job stress and side effects, especially for insurance reviewers who are in charge of paying insurance, such as communicating with customers who claimed insurance and contributing to the company's profit. In response, this study analyzed the effects of job stress on mental health of insurance reviewers and conducted a descriptive survey study to reduce job stress of insurance reviewers and promote mental health. The analysis shows that job stress for insurance reviewers has a significant impact on mental health (+). In detail, job stress has a significant impact on all four factors: social performance and self-confidence, depression, sleeping disturbance and anxiety, and general well-being and vitality. This study showed that job stress in insurance reviewers has a significant (+) impact on mental health. Job stress can cause side effects in organizational aspects, such as reducing enthusiasm for job performance and increasing turnover and resignation rates, but it can also worsen individual physical health and cause diseases such as depression and anxiety, causing mental health to be impoverished. Therefore, in order to prevent this, appropriate work stress prevention methods and countermeasures should be provided to help reduce work stress and improve mental health.