| Summary: | 碩士 === 國立臺灣大學 === 醫療機構管理研究所 === 85 === The purposes of this study were to investigate how did a
hospital respondto the Claims Review System of National Health
Insurance , what strategieshave been implemented, and the
results so far. This research was a case study and was
designed in a cross-sectional way,and data were collected by in-
depth interviews and self-administratedquestionnaire survey.
Twenty one managing directors and staff members of amedical
center were interviewed on the subject matters from December 2 -
23,1996. A questionnaire survey was conducted on 315 attending
doctors of themedical center to examine their attitudes toward
the strategies taken by thehospital.The survey was done from
January 25 to March 8 ,1997.And the responserate was
41%.Important findings are as follows:Interviews: The
respondents knew the deduction rate of claims of their
department thebest, followed by that of the hospital and other
hospitals. The item that wasdeducted most frequently was the
use of medication. The elements ofconsideration when choosing
respond strategies were workload of the staff, thesources of
fund, recognition and willingness to comply by the staff.
Theresponding strategies that have been implemented were:
computer-aidedpre-auditing , examining over quality and quantity
of medical records,computerizing summary of medical records,
providing examples of well documentedmedical records for the
doctors to follow, practicing "consultant of reasonabledrug
usage", and setting up a team for account examination to prevent
evasionand error input.Questionnaire The recognition of "the
effects of responding strategies on deduction rate":Among 15
strategies, two of them varied with the respondent''s service
period inthe Hospital and education background, six with the
department the respondentswere in, and three with his/her own
experience of filing claims. The implementation of responding
strategies in the departments: "usingcomputer to monitor days
and dosage of description each time" was most commonlyreported
(68%), "setting up an examining team in the department to pre-
auditmedical records that were required by Bureau of National
Health Insurance" wasthe least commonly reported (26.2%).
Personal compliance to the responding strategies: the
willingness ofcompliance varied with "involvement of responding
strategies within departments", "the recognition of the effect
of responding strategies on deduction rate","being members of
NHI reviewing board ", "being managing director", "name
ofaffliated department", "experience in filing a deducted
claims", "participationin a training seminar". According to
investigated results, this study suggests the Study Hospitalto
set up an examining team in every department to be in charge of!
applicationmatters, statistics, and analysis. In addition, Clear
rewarding and penaltysystem is necessary to encourage compliance
from the staff. The suggestions tothe Bureau of National Health
Insurance are: establishing standards of claimsreview, speeding
up the process of review, and providing the reasons ofdeduction
to the applicant. Finally, it is suggested that future
researchersshould concentrate on the relationship between the
subject matters and otherrelated factors.
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