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Ann Surg Treat Res. 2017 May;92(5):370-375. English. Original Article. https://doi.org/10.4174/astr.2017.92.5.370
Jung K , Heo Y , Lee JC , Lee M , Son S , Park HS , Kim JO , Lee JH .
Department of Surgery, Ajou University School of Medicine, Suwon, Korea. jake98@daum.net
Department of Medical Humanities and Social Medicine, Ajou University School of Medicine, Suwon, Korea.
Department of Health Insurance, Ajou University Hospital, Suwon, Korea.
Gyeonggi South Regional Trauma Center, Ajou University Hospital, Suwon, Korea.
Abstract

PURPOSE: This study aimed to evaluate the situations and problems of the current health insurance fees for trauma surgeries. METHODS: We reviewed the medical records and billing data from trauma surgeries performed in the hospital from August 2012 to July 2014. The name and number of surgeries were investigated and the code and number of operations prescribed by surgeons were compared with the number of cases actually billed to insurance. In addition, the results returned by the Health Insurance Review & Assessment Services (HIRA) after deduction were investigated and compared to verify the insurance review findings. RESULTS: During the study period, total 1,534 trauma surgical procedures were performed for a total of 253 trauma patients. Based on names, 1,092 procedures were performed; however, 442 cases (28.8%) could not be prescribed because of lack of proper insurance codes for the procedures. A total of 1,046.5 surgical procedures were prescribed by surgeons, adjusted by the insurance team, and finally billed to the HIRA; 162 bills were returned from the HIRA after rate reductions, corresponding to a reduction rate of 15.5%. The major reason for reduction was “fee criteria and limited number”. The compensation rate for billed surgical procedures was 84.5%. CONCLUSION: The high reduction and low compensation rate for trauma surgery under the current Korean National Health Insurance System need to be reviewed and improved. Furthermore, it is necessary to establish new criteria for surgical procedures fees for latest ones such as damage control surgery performed on severe trauma patients.

Copyright © 2019. Korean Association of Medical Journal Editors.