| Summary: | 碩士 === 淡江大學 === 保險學系保險經營碩士在職專班 === 98 === Claim is insurance company fulfills promise for customers. Presently, the health insurance payment that under the total of claim payment is about 5%-11%. However, according to the actual claims, the percentage of health insurance payment is up to 90%, which is the main concern of the claim management. This study puts claim management as the focus to analyze reasonable claim business distribution system and a proper claim operation organization. Also it will model the actual claim experiences and professional techniques and transmit the automatic and professional claim tools. It will make the claim management more completed. The computerized system which include process management, profession system, ethical risk detective tools and management reports, which will strengthen the efficiency of claim operation. In addition, in order to decrease the misconducts in the claim department itself, the explaination for internal accuse such as actual claims, professional techniques and claim ethics that happens within the insurance companies would be required.
The health insurance, payment of the commercial insurance is about 17.78% compare whit National Health Insurance payment scale. Although the data is not very accurate, they are similar in the actual investigating system. In this study, it has comparison and discussion between the claim control of commercial health insurance and National Health Insurance screening systems and the reciprocal pattern between these two as well. It will finalize the cooperation of these two in the future under the appropriate lawful consideration in order to decrease the insurance fraud and waste of medical resource.
This study proposes the conclusion for claim operation. It also provides the suggestions for the related departments. The conclusions are as followings:
1)The actual claim besiness should be considered more for future health insurance products.
2)The training of the claim processing staffs should emphasize the hand-on experiences, professional skills and work ethics.
3)Setting up the reasonable claim business division and proper claim processing organization.
4)Setting up a conscientious for claim adjusted operation consistency SOP .
5)Having the automatic claim system to reduce the staffs'' learning difficulties.
6)Having the professional claim decision tools including the professional processing system and presentation tools.
7)Enhancing the cooperation with the Bureau of National Health Insurance to decrease the ethical risk.
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