Healthc Inform Res.  2012 Sep;18(3):215-224. 10.4258/hir.2012.18.3.215.

Health Insurance Claim Review Using Information Technologies

• Park YT
• Yoon JS
• Speedie SM
• Yoon H
• Lee J

• KMID: 2229473
• DOI: http://doi.org/10.4258/hir.2012.18.3.215

Abstract

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.

Keyword

Health Information Technology; Medical Informatics; Clinical Informatics; Medical Information Science

MeSH Terms

Automatic Data Processing
Health Personnel
Humans
Inpatients
Insurance Claim Review
Insurance, Health
Medical Informatics
Outpatients

Figure

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  Figure 1 System structure. CRS: claim review support, DW: data warehouse, SAN: storage area network, HIRA: Health Insurance Review and Assessment Service, ATM: asynchronous transfer mode.

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  Figure 2 Software composition.

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  Figure 3 Information flow of claim data processing [7]. CRS: claim review support, EDI: electronic data interchange, HIRA: Health Insurance Review and Assessment Service, PARE: payment request.

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  Figure 4 Information flow of the payment request data. HIRA: Health Insurance Review and Assessment Service, SAM: sequential access method, SOAP: simple object access protocol, LDAP: lightweight directory access protocol, ES: electronic signature, I/F: interface.

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  Figure 5 Five stages of automatic data processing procedures [7]. CK: check-up, DUR: drug utilization review.

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