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요양급여비용 자율점검제도 발전방안

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Type
Research report
Author(s)
이성우김태완김진휘
Issued Date
2020-12
Keyword
Voluntary monitoring systemprevention of fraudulent claimvoluntary improvementpreventive policing activityeffect analysisCITSbenefit estimationARIMA
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.
Publisher
건강보험심사평가원
URI
https://repository.hira.or.kr/handle/2019.oak/3051
Alternative Title
Voluntary monitoring system development measures for National Health Insurance benefit
Table Of Contents
요 약 ⅰ

제1장 서론 ----------------------------- 1
1. 연구 배경 ----------------------------- 1
2. 연구 목적 ----------------------------- 5
3. 연구 내용 및 방법 ----------------------------- 5

제2장 자율점검제 문제점 및 개선지점 발굴 ----------------------------- 9
1. 사업 현황 ----------------------------- 9
가. 시행 배경 ----------------------------- 9
나. 제도 현황 ----------------------------- 10
2. 문제점 및 개선지점 발굴 ----------------------------- 15
가. 선행 연구 문헌 고찰 ----------------------------- 15
나. 실무 담당자 의견수렴 ----------------------------- 17
3. 업무 개선을 위한 이론적 근거 마련 ----------------------------- 22
가. 기존 제도의 이론적 배경 ----------------------------- 22
나. 예방적 경찰활동 이론과 자율점검제도 ----------------------------- 24

제3장 자율점검제 도입 이후의 효과 분석 ----------------------------- 31
1. 분석 개요 ----------------------------- 31
가. 분석 대상 ----------------------------- 31
나. 분석 내용 ----------------------------- 35
다. 분석 방법 ----------------------------- 35
2. 분석 결과 ----------------------------- 40
가. 측두하악관절규격촬영 ----------------------------- 40
나. 건식부항술 주관법 ----------------------------- 54
다. 유방 절개생검 ----------------------------- 61
라. 약국 차등수가(시범사업) ----------------------------- 70
마. 약국 차등수가(본사업) ----------------------------- 77
바. 하지정맥류 수술 ----------------------------- 84
사. 정맥마취-부위(국소)마취 ----------------------------- 91
아. 한방 첩약 조제 당일 진찰료 ----------------------------- 98
자. 인·후두소작술 ----------------------------- 104
차. 촉탁의 원외처방 진찰료 ----------------------------- 109
카. 의치 조직면 개조 ----------------------------- 122
타. 기질성 정신질환의 개인정신치료 ----------------------------- 130
파. 병변내 주입요법(트리암시놀론주) ----------------------------- 141
3. 자율점검제 시행에 따른 재정절감 효과 ----------------------------- 146
4. 소결 ----------------------------- 149

제4장 결 론 ----------------------------- 153
1. 자율점검제도 발전 방안 ----------------------------- 153
가. 문제의 발굴 ----------------------------- 153
나. 문제의 분석 ----------------------------- 155
다. 개입 활동 ----------------------------- 157
라. 사업 평가 ----------------------------- 158
마. 협력 강화 ----------------------------- 159
바. 사업 단계별 개선 방안 ----------------------------- 160
2. 연구의 한계 ----------------------------- 162

참고문헌 ----------------------------- 164
ABSTRACT ----------------------------- 165
부 록 ----------------------------- 167
Publisher
건강보험심사평가원
Location
KOR
Citation
이성우 et al. (202012). 요양급여비용 자율점검제도 발전방안.
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