• The Journal of the Korean life insurance medical association
• /
• v.26
• /
• pp.41-53
• /
• 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 Journal of the Korean life insurance medical association
• /
• v.28 no.1_2
• /
• pp.31-35
• /
• 2009

Background : Many of internists have been working for insurance industry. Insurance medicine is use of medical knowledge for insurance industry. There is social role of insurance medicine in terms of soundness of insurance administration. Recently social role of internists also have been being watched. Although theme of insurance medicine is medical risk selection, insurance claims administration also needs medical experts'opinion. There are not any corroborative study of medical consulting for insurance claims. Among insurance industry, someone called this medical review of insurance claims as 'medical claims review'. Aim : To investigate usefulness of medical review of insurance claims. Design : Questionnaire survey with claim staffs in one of insurance claim adjustment company in Korea. Methods : 265 claim staffs were divided into 4 groups and conducted survey using a questionnaire of 20 questions. Utility score, job satisfaction score, and difficult factors of claims administration were measured. Results : Utility score and job satisfaction score are highest in medical claims review group. The most difficult in claim administration to claim staffs was demonstrated to medical knowledge. Conclusion : Medical review of insurance claims is proved to be worthy. Document-based consulting method, namely medical claims review, is more useful than telephone-based simple query among claim staffs...Subjects of the medical claims review are medical record and it's principle is independent medical examination with evidence-based approach, it also has role of protecting fraud of insurance claims. Two main question types of medical claims review are verification and advice.

• The Journal of the Korean life insurance medical association
• /
• v.20
• /
• pp.28-31
• /
• 2001

• Journal of Preventive Medicine and Public Health
• /
• v.33 no.4
• /
• pp.393-401
• /
• 2000

Objectives : To evaluate the impacts of the DRG payment system on the behavior of medical insurance claimants. Specifically, we evaluated the case-mix index, the numbers of diagnosis and procedure codes utilized, and the corresponding rate of diagnosis codes before, during and after implementation of the DRG payment system. Methods : In order to evaluate the case-mix index, the number of diagnosis and procedure codes utilized, we used medical insurance claim data from all medical facilities that participated in the DRG-based Prospective Payment Demonstration Program. This medical insurance claim data consisted of both pre-demonstration program data (fee-for-service, from November, 1998 to January, 1999) and post-demonstration program data (DRG-based Prospective Payment, from February, 1999 to April, 1999). And in order to evaluate the corresponding rate of diagnosis codes utilized, we reviewed 820 medical records from 20 medical institutes that were selected by random sampling methods. Results : The case-mix index rate decreased after the DRG-based Prospective Payment Demonstration Program was introduced. The average numbers of different claim diagnosis codes used decreased (new DRGs from 2.22 to 1.24, and previous DRGs from 1.69 to 1.21), as did the average number of claim procedure codes used (new DRGs from 3.02 to 2.16, and previous DRGs from 2.97 to 2.43). With respect to the time of participation in the program, the change in number of claim procedure codes was significant, but the change in number of claim diagnosis codes was not. The corresponding rate of claim diagnosis codes increased (from 57.5% to 82.6%), as did the exclusion rate of claim diagnosis codes (from 16.5% to 25.1%). Conclusions : After the implementation of the DRG payment system, the corresponding rate of insurance claim codes and the corresponding exclusion rate of claim diagnosis codes both increased, because the inducement system for entering the codes for claim review was changed.

• The Journal of the Korean life insurance medical association
• /
• v.24
• /
• pp.43-48
• /
• 2005

• The Journal of the Korean life insurance medical association
• /
• v.26
• /
• pp.31-39
• /
• 2007

Background and main issue: In the Korean insurance market, an outstanding issue is the decrease of margin of risk ratio. This affects the solvency and profitability of insurance companies. Insurance medicine, which has been developed in Western countries, is so-called medical risk selection or medical underwriting. Medical risk selection is based on clinical follow-up study and mortality analysis methodology. Unfortunately, there have been few clinical follow-up studies, and no intercompany disease analysis system is available in the Korean insurance market. In practice, we use underwriting guidelines, which were developed by some global reinsurance companies. However, these guidelines were developed under clinical follow-up studies performed abroad. So, we cannot rule out underestimation of excess mortality factors such as mortality ratio, excess death rate, and life expectancy. It is necessary to perform medical assessment in claims administration. Comparing the insured's statement by medical records with products' benefit according to this procedure, we can make sound claim decisions and participate in the role of sound underwriting. We can call this scientific procedure as the verification of medical claims review. Another area of medical claims review is medical counsel for claims staff. Result: There is another insurance medicine in addition to medical risk selection. Independent medical assessment by medical records of insured is medical claims review. Medical claims review is composed of verification and counsel.

• Journal of Preventive Medicine and Public Health
• /
• v.27 no.2 s.46
• /
• pp.242-257
• /
• 1994

In Korea, female workforce has reached more than 40% of total working population, but the effects of work on spontaneous abortion are yet to be examined. This study as conducted to investigate the occupational effects on spontaneous abortion. Medical insurance claim data were used to examine the effects of the employment status and industry of employment on spontaneous abortion. The study population was composed of females, aged $15{\sim}44$, who were the beneficiary of medical insurance in the month of June, 1993. The working females covered by medical insurance for industrial workers, had the highest age-adjusted Spontaneous Abortion rate (SAB rate=claim frequency of spontaneous abortion/claim frequency of complication of pregnancy, childbirth and the puerperium), 6.65% whereas female dependants of medical insurance for industrial workers had the lowest age-adjusted SAB rate, 4.54%. Among industrial workers, the workers in manufacturing industry had the highest age-adjusted Spontaneous Abortion ratio(SAB ratio=claim frequency of spontaneous abortion/claim frequency of completly normal delivery), 43.2/100 whereas those in financing and service industry had age-adjusted SAB ratio, 16.2/100 and 20.5/100, respectively. The results of the study suggest the adverse effect of manufacturing Industry on reproduction. Work environments such as chemical exposures, overwork, awkard posture, and job stress should be further studied for their effects on reproductive functions of female.

• Health Policy and Management
• /
• v.26 no.1
• /
• pp.63-70
• /
• 2016

Background: Selective health benefit was introduced for decreasing economic burden of patients. Medical devices with economic uncertainty have been covered as selective health benefit by National Health Insurance since December 2013. We aimed to analyze impact of selective health benefit to medical expenditure and provider behavior focused on electrosurgery (ultrasonic shears, electrothermal bipolar vessel sealers) for gastric cancer patients covered since December 2014. Methods: We used the National Health Insurance claims data of 2,698 patients underwent gastric cancer surgery between August 2014 and March 2015. Medical cost and patient sharing per inpatient day were analyzed to verify that covering electrosurgery increased medical expenditure and changed provider behavior from open surgery to endoscopic or laparoscopic surgery. Additionally, we analyzed the claim rate of medical device or goods relating gastric endoscopic and laparoscopic surgery. Results: Medical cost and patient sharing per inpatient day were increased after covering electosurgery as selective health benefit (39,724/1,421 won). However, there were no medical expenditure increases after adjusting claim of electosurgery and patient sharing was decreased 1,057 won especially. The coverage of selective health benefit did not increase the claim rate of medical device or goods related endoscopic or laparoscopic surgery, either. Conclusion: Covering electosurgery decreased patient economic burden and did not change of provider behavior. Expanding selective health benefit is needed to decrease economic burden of severe patients. Further study should evaluate the long term effect with accumulated data.

• Journal of Convergence for Information Technology
• /
• v.9 no.9
• /
• pp.195-200
• /
• 2019

The purpose of this study is to analyze the characteristics of National Health Insurance claim data and to construct a pilot medical episode data considering it. In this study, the trends of respiratory disease (ICD10: J00-J99) cardiovascular disease (ICD10: I00-I99) from the day of onset of treatment to re-admission after admission were confirmed in Seoul, and the largest decrease was observed when the no-treatment period was 0 day. The data reduction rate when the no-treatment period is 0 day is judged to be due to the monthly separation claim of the health insurance claim data. Also, the result that there is a tendency of monthly separation request according to the type of medical treatment. Through this study, we constructed epidemic data for the pilot medical treatment considering the characteristics of the claim data of health insurance, and based on this, it can be used as a data processing method for calculating basic epidemiological information.

• The Journal of the Korean life insurance medical association
• /
• v.27 no.1
• /
• pp.33-36
• /
• 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.