Health Insurance Claim Review Using Information Technologies

박영택; 윤정식; Stuart M. Speedie; 윤호정; 이지선

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자료유형: 학술저널

저자정보: 박영택 윤정식 Stuart M. Speedie 윤호정 이지선

저널정보: 대한의료정보학회 Healthcare Informatics Research Healthcare Informatics Research 제18권 제3호

발행연도: 2012.1

수록면: 215 - 224 (10page)

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Objectives: The objective of this paper is to describe the Health Insurance Review and Assessment Service (HIRA)’s payment request (PARE) system that plays the role of the gateway for all health insurance claims submitted to HIRA, and the claim review support (CRS) system that supports the work of claim review experts in South Korea. Methods: This study describes the two systems’ information technology (IT) infrastructures, their roles, and quantitative analysis of their work performance. It also reports the impact of these systems on claims processing by analyzing the health insurance claim data submitted to HIRA from April 1 to June 30, 2011. Results: The PARE system returned to healthcare providers 2.7% of all inpatient claims (97,930) and 0.1% of all outpatient claims (317,007) as un-reviewable claims. The return rate was the highest for the hospital group as 0.49% and the lowest rate was found in clinic group. The CRS system’s detection rate of the claims with multiple errors in inpatient and outpatient areas was 23.1% and 2.9%, respectively. The highest rate of error detection occurred at guideline check-up stages in both inpatient and outpatient groups. Conclusions: The study found that HIRA’s two IT systems had a critical role in reducing heavy administrative workloads through automatic data processing. Although the return rate of the problematic claims to providers and the error detection rate by two systems was low, the actual count of the returned claims was large. The role of IT will become increasingly important in reducing the workload of health insurance claims review.

#Health Information Technology #Medical Informatics #Clinical Informatics #Medical Information Science

참고문헌 (16)

참고문헌 신청

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