A Research on Hospital Stsategies Responding to The Claims Review System of National Health Insurance -A Case Study of A Medical Center in Northern Taiwan

• Main Authors: Li, Feng-chiao, 李鳳嬌
• Other Authors: Ming-chin Yang
• Format: Others
• Language: zh-TW
• Published: 1997
• Online Access: http://ndltd.ncl.edu.tw/handle/61490136225117113203

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.