Page 47 - 2018-19全民健康保險年報

Improving Efficiency through Professional Reviews
The medical service review system is a necessary mechanism to prevent waste, safeguard quality, and maintain the public’s healthcare safety and quality. The key points of medical service reviews include: medical service items, quantity, appropriateness, and quality. An average of 356 million outpatient reimbursement claims are filed every year, which works out to an average of roughly 970,000 per day, and about 3.28 million inpatient care claims (roughly 9,000 per day) are filed each year. Based on manpower and administrative cost considerations, the review process follows two tracks: a procedural review track and a professional peer review track. Computer technology and data analysis are employed extensively in these reviews, and NHIA is striving to develop “computerized physician’s order automated review and profile analysis” computer-aided review systems in an effort to boost review efficiency.
Professional Review
Due to the immensity of reported cases, the NHIA adopts sampling during professional reviews. That is, a part of the medical records are sampled and submitted for review by medical experts. The sampling methods include random sampling and purposive sampling. The results of random sampling will be scaled down based on the deduction rate of the samples to the total population cases for deduction, while the review results obtained through purposive sampling will not be scaled down.
Following the phased implementation of a global budget payment system starting in 1998, the NHIA has also commissioned medical associations to deal with some professional medical service reviews and established management guidelines
專業審查 提升品質
Professional Review and Quality Improvement
for recruiting medical review experts. The NHIA and the commissioned related medical groups have also gradually developed mechanisms for jointly managing the various professional reviews in every region.
The setup of medical professional review notices requires first collecting the opinions of specialized medical associations, physician associations, and hospital associations after discussions at specialized expert consultation meetings made up of medical experts with relevant clinical or practical experience. Beginning 2017, the operational schedule was adjusted from once every two years to a case by case basis. With common professional medical treatment practices or surgeries as themes, the review notices underwent overall review and revision, logical arrangements were made, and drug payment regulations served as references to carry out coding, thereby facilitating informatization and providing a reference for review physicians.
More Efficient Review through Information Technology
The NHIA has gradually pushed forward the digitization of medical reports, which have been compiled over the years to create the NHI database, which is unique in the world. Thanks to this digitization process, the NHIA can quickly and efficiently review claims submitted by healthcare providers, and detect abnormal situations. The information collected in the NHI’s vast database is also used to analyze future policy directions, initiate relevant measures, and prevent the waste of medical resources.
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