Escolar Documentos
Profissional Documentos
Cultura Documentos
Enhancement
Expansion
Introduction
Portal system
Establishment of DW system
DW, OLAP, Data Mining system
Establishment of National Health
Insurance Data Network
Host System Client/Server
Establishment of Health Insurance
Review & Assessment Service
Development of Review &
Assessment system
system
Control system for headquarters
and branches
Information security system
Current status
About 86,980
providers
USD 56 billion
Requirements
Stable
management
of large scale
data system
Number of servers
Data volume
1,887 TB
Number of programs
40,000
ICT employees
210 people
Collection
Health Care
Provider
Medical fee claims
Provider info
Data for assessment
Prescription and
Dispensing records
Utilization
NHIS
EDI
Portal System
ReviewAssessment System
Utilization
WEB
Review Assessment
MCPoS
Review
System
Assessment
System
MoHW
Pharmaceuticals
Record of
drug supply
WEB
Providers
Portal
Portal for
the public
DUR
Provider
management
system
On-Site Development of
Investigation benefit standard
and policy
the Korea
Veterans
Welfare
Corporate
Treatment
MFDS
Center for
connecting
4 major
insurances
Dedicated
line
DUR
DW
system
Data mining
Connecting
system
Local
governments
Portal
system
DR-review
system
DR-portal
system
Dedicated network
DR storage
DR-DUR
system
External user
DDoS Defense
system
Network
security
(2nd stage)
Server
security
(3rd stage)
DB security
(4th stage)
Access control
Firewall
Database
Intrusion route
Server OS security
Application program security
DB encryption
Firewall
Invasion prevention system
DDoS defense system
Internal user
Stages
Anti-virus
File encryption (DRM)
Security measures
Stage 1- PC security
User authentication, central management of vaccine, document security [DRM) and flash
memory access control
Firewall and intrusion blocking system, web firewall and DDoS defense system, VPN
Stage 4 - DB security
International Patent
ISO9001
11 DQC-M(Management)
11, 12 DQC-V(Value) DW Platinum Class(99.99%)
E-claims Agencies
01: 64% 06: 90%11: 99%
* EDI; Electronic data interchange
- Initially, the opening fees were waived and usage fees were reduced
- Medical and pharmaceutical association meetings
- Contributing associations and medical institutions were provided a reward
- Medical fee claims fee for free: Using regular internet, transit costs reduced
(each individual medical institution 136-16,300USD annually)
- Transmission capacity limitations expanded (80MB500MB),
visual materials can be submitted easier
- Using HIRAs claims error pre-check service, claims returned significantly
reduced
- By simplifying claims procedure, the processing speed increased more
than 3 times
- From claims steps until review determining, the whole process was handled
in one stop
1
5
1
Healthcare
Provider
Diskette
EDI
MCPoS(Web Portal)
Portal
Simple error
checkup
Claim Submission
Processing
Benefit Standard
Data Review
Screen Review
Review
Standard
Prescription Index
DW System
4
Review Closing
Review Decision
5
Payment Information
Storage
Construction of
Payment Information
National Health
Insurance Service
EDW
Mart
Notification of
Review Results
Eligibility
Confirmation
Appeal Management
Appeals
Healthcare
Provider
Re-Evaluation Decision
Evaluation of
Quality Assessment
Calculation File
Construction
Statistic Analysis
1) Claim System
0.3%
2) Review System
95.4%
4.3%
Stage 2
Stage 3
Stage 4
Stage 5
Stage 6
(Writing CK)
(Automatic CK)
(Drug Inspection)
(Benefit-Std CK)
(Disease-specific CK)
(FLEX CK)
Verifies against
Verifies drug
Reviews
Drug interaction
Verifies the
Verifies codes,
required field
unit-prices,
guidelines
interaction
simple and
& overlapping
(omission, error, or
calculations, etc.
(Governmental
& duplication
frequent disease
prescription
duplication, etc.).
regulations, etc.)
-A (error in unit price)
Returns claims
that more than
30% of fields
are errors or
-F (document
omission)
- Reviews claims
using algorithms
-K (coding error)
based on the
-Etc.
guidelines
with algorithms
check-up
Check for cases
- Contraindication
without human
* Drug-Drug
which exceeds
input
one-day or total
* Drug-Age
(Children)
* Pregnancy
- Detects multiple
- Benefit guidelines
by drug code
- Contraindication
* Co-medication,
missing to
prescriptions with
providers
low dosage
- Overlapping presc.
prescriptions.
- Duplication
age, pregnancy
drug code(one-day,
total benefit caps)
CK: Checkup
After passing through the computerized checkup process, some claims are sent to
review department for manual staff review. Review process is finalized after staff
Distribution
Check
Review
Closing
According to the
Distribute benefit
claims data to
staff check
status to result
review staff
providers trend
confirmed
and electronic
finalize results
(Electronic process
checkup results
closing)
Definition
Data
configuration
System
utilization
Drill Down
Drill Up
2007
2008
2009
2010
2011
2012
2013
2014
2015
117
10
12
13
13
13
14
14
14
13
Medical
Treatment Data
350
29
34
37
38
39
42
42
44
35
Dispensing
Data
401
41
41
44
45
45
46
45
47
47
Claims Data
Claims data: information for benefit claim patient, disease code, amount of benefit, etc.
Medical treatment data: received treatment (consultation, treatment, surgery, etc.)
Dispensing data: dispensed drugs from pharmacies
Private usage
Healthcare Provider
Insured
DW System
Media (statistics,
certain disease, etc.)
Improving Quality
Web Portal for Claims
Quality Assessment
Cost Savings
Review System
Data Warehouse
Assessment
System
R&D Support
Portal for
healthcare providers
Hospital profile
system
Prescription
data via DUR
Concurrent Check
before filling the
prescription
Policy Making
Data Mining
DUR-Portal
Fraud Detection
Safety &
Convenience
MFDS DB
KPIS
KPIS-Portal
National
Drug
Management