요양급여비용 자율점검제도 발전방안

Abstract

Errors in benefit claims have surged due to increasingly diversified fee schedule and benefit criteria and complicated benefit claim process. In response, a voluntary monitoring system was adopted in December 2017. Under the system, providers that inspected and reported errors in claim submission voluntarily are exempted from administrative dispositions, and only have to refund the wrongfully provided benefit. The voluntary monitoring system intends to move away from the traditional deterrence theory and punishment-oriented prevention efforts, and pursue a new priority of autonomy and prevention. The system aims to rectify treatment practice of providers on a voluntary basis and maximize prevention effect. The purpose of this study is to identify issues and areas of improvement in the voluntary monitoring system. To examine theoretical background, preventive policing activity was reviewed. Based on comparison of before and after the system introduction and effect analysis, suggestions were produced for improvement and further development. The effect of the voluntary monitoring system was analyzed by comparing before and after the system introduction among both providers that adopted and did not adopt the system. The comparison consisted of i) changes in distribution and outlier, ii) statistical verification using CITS on trend change, iii) shifting trend to similar practice, and iv) in consideration of ballon effect, gaps between actual and predicted prevention amount were quantified using ARIMA (p,d,q) model. Providers that reported their results showed statistically significant improvements, but those that did not showed no noticeable changes. Items that were recently added to the system required a longer period of monitoring time to compare the practice between before and after the system introduction. For further development of voluntary monitoring system, it is important to discover more items by multidimensional analysis and to identify areas for correction in a more concrete manner. When the system was introduced, only partial providers participated due to insufficient workforce and IT infrastructure. As we complement analysis method and add more resources, the Health Insurance Review and Assessment Service will be able to better contribute to correcting claim practice and preventing fund leakage of the national health insurance system.