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KMID : 0365420090280010031
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Journal of the KLIMA
2009 Volume.28 No. 1 p.31 ~ p.35
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Usefulness of medical review in the insurance claims
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Lee Eui-Kwan
Hwang Jin-Sup
Lee Sin-Hyung
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Abstract
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Background : Many of internists have been working for insurance industry. Insurance medicine is use of medical knowledge for insurance industry. There is social role of insurance medicine in terms of soundness of insurance administration. Recently social role of internists also have been being watched. Although theme of insurance medicine is medical risk selection, insurance claims administration also needs medical experts’opinion. There are not any corroborative study of medical consulting for insurance claims. Among insurance industry, someone called this medical review of insurance claims as ’medical claims review’.
Aim : To investigate usefulness of medical review of insurance claims.
Design : Questionnaire survey with claim staffs in one of insurance claim adjustment company in Korea.
Methods : 265 claim staffs were divided into 4 groups and conducted survey using a questionnaire of 20 questions. Utility score, job satisfaction score, and difficult factors of claims administration were measured.
Results : Utility score and job satisfaction score are highest in medical claims review group. The most difficult in claim administration to claim staffs was demonstrated to medical knowledge.
Conclusion : Medical review of insurance claims is proved to be worthy. Document-based consulting method, namely medical claims review, is more useful than telephone-based simple query among claim staffs...Subjects of the medical claims review are medical record and it’s principle is independent medical examination with evidence-based approach, it also has role of protecting fraud of insurance claims. Two main question types of medical claims review are verification and advice.
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KEYWORD
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insurance medicine, claims, underwriting
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