Trauma surgery without proper compensation under the current Korean National Health Insurance System

Kyoungwon Jung; Yunjung Heo; John Cook-Jong Lee; Mijin Lee; Suni Son; Hee Suk Park; Joo-Ok Kim; Jeong Hee Lee

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자료유형: 학술저널

저자정보: Kyoungwon Jung (Ajou University School of Medicine) Yunjung Heo (Ajou University School of Medicine) John Cook-Jong Lee (Ajou University School of Medicine) Mijin Lee (Ajou University School of Medicine) Suni Son (Ajou University Hospital) Hee Suk Park (Ajou University Hospital) Joo-Ok Kim (Ajou University Hospital) Jeong Hee Lee (Ajou University Hospital)

저널정보: 대한외과학회 Annals of Surgical Treatment and Research Annals of Surgical Treatment and Research Vol.92 No.5

발행연도: 2017.5

수록면: 370 - 375 (6page)

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Purpose: This study aimed to evaluate the situations and problems of the current health insurance fees for trauma surgeries.
Methods: We reviewed the medical records and billing data from trauma surgeries performed in the hospital from August 2012 to July 2014. The name and number of surgeries were investigated and the code and number of operations prescribed by surgeons were compared with the number of cases actually billed to insurance. In addition, the results returned by the Health Insurance Review & Assessment Services (HIRA) after deduction were investigated and compared to verify the insurance review findings.
Results: During the study period, total 1,534 trauma surgical procedures were performed for a total of 253 trauma patients. Based on names, 1,092 procedures were performed; however, 442 cases (28.8%) could not be prescribed because of lack of proper insurance codes for the procedures. A total of 1,046.5 surgical procedures were prescribed by surgeons, adjusted by the insurance team, and finally billed to the HIRA; 162 bills were returned from the HIRA after rate reductions, corresponding to a reduction rate of 15.5%. The major reason for reduction was “fee criteria and limited number”. The compensation rate for billed surgical procedures was 84.5%.
Conclusion: The high reduction and low compensation rate for trauma surgery under the current Korean National Health Insurance System need to be reviewed and improved. Furthermore, it is necessary to establish new criteria for surgical procedures fees for latest ones such as damage control surgery performed on severe trauma patients.

#Wounds and injuries #Health insurance #Operative surgical procedures #Korea

참고문헌 (17)

참고문헌 신청

[학술지(정기간행물)] - Jung KY / 2001 / Problems in trauma care and preventable deaths / J Korean Soc Emerg Med 12 : 45 ~ 56

[학술지(정기간행물)] - 강정호 / 2011 / 제주도내 예방 가능한 외상 사망률과 처치 과정의 문제점 / 대한응급의학회지 22 (5) : 438 ~ 445

[학술지(정기간행물)] - 김현 / 2012 / 한국의 예방 가능 외상 사망률과 외상 처치 체계의 변화 / 대한응급의학회지 23 (2) : 189 ~ 197

[학술지(정기간행물)] - 김윤 / 2006 / 국내 응급의료체계의 예방가능한 외상 사망률과 처치과정의 문제점 / 대한응급의학회지 17 (5) : 385 ~ 394

[보고서] - Kim Y. / 2010 / A study on validity of establishment and management model of regional trauma centers in Korea

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