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18(03) 215-224
Health Insurance Claim Review Using Information Technologies
Young-Taek Park, PhD1, Jeong-Sik Yoon, MS2, Stuart M. Speedie, PhD3, Hojung Yoon, MD4, Jiseon Lee, MS2
1Health Insurance Review & Assessment Research Institute, 2Department of International Cooperation, Health Insurance Review & Assessment Service, Seoul, Korea; 3Institute for Health Informatics, University of Minnesota, Minneapolis, MN; 4Department of Medicine, VA Loma Linda Healthcare System, Loma Linda, CA, USA
This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
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.
Healthcare Informatics Research 2012 Sep; 18(03) 215-224
Keyword : Health Information Technology, Medical Informatics, Clinical Informatics, Medical Information Science

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