Page 49 - 2018-19全民健康保險年報

專業審查 提升品質
Professional Review and Quality Improvement
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Automated Review System for Medical Orders
The NHIA has developed automated review system for medical orders, i.e. automated auditing rules and no-payment regulations for NHI covered services, fee schedules, NHI drug list, and NHI medical expense review guidelines (such as age restrictions, gender restrictions, specialist physician requirements, etc.)The system rules out no- payment items directly and helps to improve the accuracy of claims submitted by medical providers and thus boosts review efficiency.
Profile Analysis
In recent years, the NHIA has also actively implemented a profile analysis-based review system, which is able to review and manage irregular medical utilization by medical institutions; the following specific measures are currently in place:
(1) Use of statistical analysis, detect abnormalities in patient visits, and diagnostic and treatment practices and expense claims irregularities, where the results serve as a reference in professional reviews. This allows the focus of professional reviews to be shifted from individual cases to treatment practices and operating patterns.
(2) Medical community representatives are invited to discuss and co-develop file analysis to review anomaly non- payment indicators, use claims data to carry out reviews on diagnosis and treatment types of medical institutions, and set threshold values targeting various indexes. For the anomaly part, the procedure review is used to carry out payment reduction to save labor costs.
(3) The NHIA has since September 2014 set up the “Central Intelligence System, CIS” to unify control of important items. For claims suspected of abnormally consuming NHI medical resources, the computer automatically selects anomaly cases, and lists them in the sampling or and flags them. The abnormal information and retrieved medical records are sent for professional review to confirm whether they meet NHI requirements. The system has currently developed about 100 anomaly-screening indicators through the use of 4 main dimensions, namely NHI outpatient care, NHI hospital ambulatory care, NHI pharmaceutical drugs, and NHI specified diagnosis and treatment.
Facilitating Professional Review
From 2014 to 2016, the NHIA expanded the use of digital reviews using information technology, and strengthened the information integration function of the “Intelligent Peer Review Online System”. This effort included the establishment of automatic links to health insurance payment regulations, review guidelines, case history e-files, and review focal point information, and the addition of reminder mechanisms and individualized settings helps review experts to perform their work accurately and efficiently.
Named Professional Double Review
In response to the suggestions from all sides to reveal names of the reviewers to show responsibility due to disparities in professional review opinions. The NHIA has since October 2016 implemented the “named professional double review” pilot plan, with hospital global budget medical expenditure as the scope. For the professional “double review” part, specific cases are targeted for review by two
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