High-Value Medical Information and Quality Claims Review

Abstract

The big data generated by the National Health Insurance (NHI) medical information system is the most important asset that Taiwan possesses in promoting national digital policies. Hence, it is the NHI’s priority to maintain the quality of the dataset and its interoperability with healthcare facilities. This chapter presents the process for claiming medical expenses in detail and gives examples of how the National Health Insurance Administration (NHIA) proactively assists providers to submit accurate claims.

Although most medical examination and test results, images, etc., are uploaded in a timely manner to the NHI medical information system, the NHIA plans to bundle the reimbursement to the provider with data upload to further its accuracy. The author explains the strategies applied to strengthen the connection between the hospital information system of contracted institutions and the National Health Insurance MediCloud System (NHI MediCloud System) to improve the accuracy of the data uploaded, such as medical visit identifier, instant upload, and the write-off mechanism.

The long-term collaboration among the NHI, contracted institutions, and information system vendors is the key to guaranteeing the quality of the dataset.

Introduction

The medical expenses claimed by contracted medical institutions are mainly paid by the insurance premiums from those insured. The insurance premiums are limited resources and belong to public assets. To maximize the effectiveness of the premiums paid by those insured, and to make sure the medical resources are used appropriately on individuals, the National Health Insurance Administration (NHIA) aims to avoid unnecessary or inappropriate medical services and reimburse properly the providers who perform necessary and legitimate medical services.

Review Process of Medical Expense Claims

The NHIA complies with the National Health Insurance (NHI) Act and regulations, such as Article 62, “The insurer shall pay the medical expenses, according to the reviewed points, declared by contracted medical institutions.” Article 63 “The insurer, in order to examine the item, quantity, and quality of the medical service of this insurance provided by the contracted medical institutions, shall appoint medical and pharmaceutical specialists who have clinical or relevant experience to conduct the review, which should be based on the approved payment; the review work should be assigned to the relevant professional agency or group. Review of the medical services in the preceding paragraph shall be done before, during, and after the matter; sampling or case analysis will be the methods used.” Therefore, counseling and review are necessary.

The Review Process

The regulations for medical claims processing, and review of the medical services of the NHI (hereinafter referred as the “Review”) are authorized by the NHI Act to specify medical expense claims, procedures and schedules, and review of medical services (Fig. 10.1) as follows:

Fig. 10.1

Flow chart of medical claims processing and review

• 1. Pre-authorization review

  The NHIA could conduct pre-authorization reviews on the medical services, medical devices, and pharmaceuticals that are high risk, expensive, or easily abused in accordance with the fee schedule. If the contracted medical institution fails to make application of the medical services or report an item that is required for pre-authorization review, the NHIA can reject the reimbursement of the cases. The contracted medical institutions shall apply for pre-authorization reviews according to patient’s conditions evaluated by physicians. The NHIA shall complete the pre-authorization review within 2 weeks and notify the contracted medical institutions. Furthermore, patients can also access the website of the NHIA regarding the progress of their applications (https://med.nhi.gov.tw/iwse0000/IWSE1010S02.aspx).

• 2. Review of medical claim

  The NHIA shall review the medical expense cases claimed by contracted medical institutions within 2 years, and these reviews include:

  • (a) Procedure review

    The NHIA is striving to develop computerized case-by-case review (also known as automated medical order review) or file analysis. Some claimed cases shall be ruled out from the procedure review, if those cases are noncompliant with regulations of the NHI—for instance, eligibility of the insured, scope of coverage, medical service items and fee schedules, pharmaceutical benefit, and reimbursement scheme.

  • (b) Professional review

    Considering the capacity for professional review, there are two sampling methods: random sampling and purposive sampling. The random sampling means that medical expense claims will be randomly selected according to the sampling rate and the purposive sampling will be selected based on the results of the file analysis. The NHIA has implemented a global budget payment system, which was divided into four sectors, such as dental care, traditional Chinese medicine, primary-level Western medicine, and hospital care. According to the Act, the NHIA entrusted the Taiwan Hospital Association, Taiwan Medical Association, Taiwan Dental Association, and National Union of Chinese Medical Doctors’ Association, R.O.C., with appointing medical and pharmaceutical specialists who have more than 5 years of teaching, clinical, or practical experience and have not violated the relevant health insurance laws and regulations, to conduct the professional review.

    The medical services, medicines, and medical devices claimed by contracted medical institutions are subject to professional review, and if there are cases in which the medical services, drugs, and medical devices are inconsistent with the diagnosis of the disease or are unnecessary for examinations and hospitalization, the reimbursements will be reduced accordingly. For random sampling, the number of points will be scaled down based on the same proportion of sampling or the upper limit of scaled down negotiated by each sector of the global budget, whichever is lower, will be accepted; whereas for purposive sampling, the number of points will not be scaled down.

• 3. On-site review

  The NHIA may inform the contracted medical institutions about the results of the file analysis from time to time, and designate personnel to conduct an on-site review of the manpower, medical facilities, and medical services provided by the medical providers. Thus, if the medical services were found to be improper or violated, consultation should be given for further improvement; also, the following measures could be taken according to the regulations, such as strengthening review frequency, reducing reimbursement, or conducting specific investigations under severe circumstances.

Relevant Regulations and References for the Review System

Regulations related to the reviews of medical expenses of the NHI include the “National Health Insurance Act,” the “National Health Insurance Medical Service Payment Items and Fee Schedule,” the “National Health Insurance Drug Dispensing Items and Fee Schedule,” and the “National Health Insurance Medical Claim Review Notices,” etc.. All laws and regulations are published on the website of the NHIA Global Information Network.

Administrative Remedy Mechanism for Contracted Medical Institutions

There are three levels of administrative remedy for the NHI medical claims: preliminary review, appeal review, and dispute review. Although the contracted medical institution submits the medical claims, from the 1st of the month after the contracted medical institution provides medical services, it has been entering the NHIA’s preliminary review. If the contracted medical institution finds the determination of the preliminary review unacceptable, it may file a petition stating the reasons and accompanied by documentary evidence and request for an appeal review. The abovementioned petition shall be made within 60 days from the date of arrival of the notification from the NHIA. If the insured person or the contracted medical institution remains unconvinced of the decision of the appeal review, they can submit a dispute review to the National Health Insurance Dispute Mediation Committee (another independent unit) of the Ministry of Health and Welfare (MOHW, see Fig. 10.2). The procedures of the dispute review application, the timeline of the application period, and the attached documents can be found on the website of the National Health Insurance Dispute Mediation Committee (https://dep.mohw.gov.tw/NHIDSB/lp-1607-117.html).

Fig. 10.2

Medical claim, review, and appeal process

Strengthening Front-End Claims Management

For the sustainable development of the NHI system, the NHIA continues to conduct medical expense review operations under the premise of respecting the medical profession. It is used to guide contracted medical institutions to provide medical services in accordance with the payment regulations, avoid detractions from the compensation of necessary medical services, and return the limited resources of the NHI to reasonable payment for conscientious medical personnel. The real purpose of the review is to implement the regulations, not to deduct the payment. Therefore, for the more transparent review information, the NHIA plans to proactively remind the contracted medical institutions about the management priorities before the medical expenses claimed.

Progress the Review Operation to Avoid Deprivatizing Disputes

Owing to the high level of medical accessibility in Taiwan, the average number of medical visits per person per year is currently 15, about 370 million claims are made in a year, and it is impossible to conduct professional reviews of all claims while considering manpower and administrative costs. Through big data analysis, the NHIA submits sample medical records to medical peers for professional review, and the sample’s medical expense reduction rate is taken as the reduction rate of the population.

However, the operations of professional peer reviews had caused considerable controversy in the past. There were even rumors that the reviews were carried out by part-time workers, or the deletion was determined randomly by electric fans. The results of the deletion also triggered protests by physicians or complaints through social media platforms. One of the main reasons for such controversial issues was that the passive review mechanism did not provide full disclosure to medical institutions to acknowledge the management priorities, which led to a sense of deprivation of medical personnel who worked hard in health care.

To cope with controversies from the old style reviews in the past, the NHIA not only improves the review strategies and methods continuously, but also executes a more proactive and transparent method to allow contracted medical institutions to manage together. Meanwhile, the NHIA clearly reminds the contracted medical institutions that their main responsibility is to set management priorities on taking care of patients, so as to strengthen the institutional management mechanism.

Since 2018, the NHIA has assembled big data profiles and consultations of crucial abnormal cases from medical expertise to feedback to medical institutions as references to facilitate their self-improvement. For example, the case “Appropriateness of reprocessing after total hysterectomy” concerned the patient who received a total hysterectomy, if subsequent uterine-related treatment was performed, there was a certain degree of unreasonableness, and it was necessary to check how appropriate it was. In another case, “Management of abnormal declaration of new oral drug for hepatitis C” (Fig. 10.3), according to Point 6 of Item 9 of the “Implementation Plan of the Payment for New Oral Drugs for Hepatitis C in the NHI (revised on 21 September 2020),” which was announced by the NHIA, each case can only have one treatment combination and the payment is limited in one treatment course. However, according to statistics, from January 2017 to December 2018 in all hospitals, it was found that there were abnormal situations such as repeated treatment combinations, and the number of medical claims exceeded the upper limit of the course. The total number of relative value unit (RVUs) deducted was 43 million. The NHIA has also conducted automated medical reviews to prevent the contracted medical institutions from claiming in the wrong way.

Fig. 10.3.

Query the case feedback

Pre-Inspection of Medical Expense Claims

Many clinicians claim that most of the deletions are caused by the unfamiliarity of the payment regulations; therefore, the NHIA builds an inspection program before the review, such as payment regulations being limited to specific payment items that must be implemented for specific patients’ age, gender, or physician’s specialty qualifications. The relevant payment items and prescribed procedures have been built for pre-inspection by contracted medical institutions before uploading the claims, so as to reduce the subsequent deletions. For instance, “artificial electronic ear” is limited to patients aged under 18, the use of patients over 18 years old is not in compliance with the regulations. In addition, the medical service “68040B/Transcatheter Aortic Valve Replacement” must be performed by a cardiologist and a cardiac surgery specialist in a joint operation. Therefore, it is not in compliance with the requirements if physicians who do not have the front-listed specialist qualifications perform the operation.

Implementation of Institutional Self-Management

The NHIA upholds the spirit of cooperating with institutions, to cope with past passive review mechanisms, and to provide a more transparent and active reminder mechanism, so that the contracted medical institutions can access the management priorities and merge them into the institutional self-management. Assembling of resources and undergoing joint management programs not only reduce the increasing number of disputes from the reviews but also simplifies the follow-up administrative tasks, such as reclama, dispute mediation, and others, to jointly create new value for the NHI.

Integrating Examination and Test Results and Medical Claims Uploaded by Contracted Institutions

To enable medical professionals to quickly query the medical information of patients in different medical institutions for diagnosis and treatment when people are seeking medical care and improve patient safety and efficiency of medical care, the NHIA actively assists in increasing the network bandwidth of contracted medical institutions and promotes the “National Health Insurance Incentive Plan of Medical Institutions Querying Patients’ Medical Information in Real Time” (hereinafter referred to as “Plan of Querying in Real Time”) to speed up the information transfer. This plan not only allows medical institutions to upload examination and test results in real time and query patients’ medical information when people are seeking medical care but also assists in finding abnormalities by artificial intelligence (AI) review. In addition, people can query medical information through the National Health Insurance Mobile Easy Access mobile application (NHI Express app) to strengthen self-health management .

Strengthening the Network Infrastructure and Coverage Rate

The first key to speeding up data flow is the network infrastructure. In the past, most of the primary-level clinics submitted the claim through an asymmetric digital subscriber line to the NHI virtual private network (VPN), which was slow and poor in quality. Therefore, the NHIA strove for subsidies to build a fiber-optic network and continued to coordinate preferential rental plans with telecommunication operators. Based on the principle of encouragement and gradual implementation, the NHIA has subsidized the monthly rental fees for the leased-line network for medical institutions since 2014. However, the subsidy method is to subsidize 50% of the network expenses first, and then the remaining 50% will be subsidized after the medical institution reaches the target set by the NHIA. Medical institutions have deployed fiber-optic networks through this program, and the fiber-optic network deployment rate of Western medical institutions has increased from 37% in 2015 to 94% in February 2021 (Table. 10.1).

Table. 10.1 Virtual private network bandwidth upgrade from an asymmetric digital subscriber line to optical fiber

Improving the Integrity of Real-Time Uploaded Data

After the promotion of the My Health Bank System in 2014, people generally expressed their willingness to access their examination and test results to facilitate self-care for health, and the NHIA also followed this opinion to develop the Plan of Querying in Real Time. In 2015, the examination and test results and discharge summary was added; in 2016, the implant of artificial joints data were added; in 2017, the referral data were added, and the monthly rental fees for the mobile network were subsidized to facilitate the data transmission and query, whereas medical institutions provided home care services outside the hospital or provided medical services in the underserved and remote areas; in 2018, medical image data were added, such as computed tomography (CT), MRI, X-rays, and clinical microscopy, and the subsidies for increasing network bandwidth in hospitals were expanded to accelerate transmission of medical image data; from 2019 to 2020, the uploaded items were added continuously, and there were a total of 689 rewarded upload items (642 kinds of examination and test results, 47 kinds of medical images) as of February 2021; in 2020, the claimed medical orders of rewarded upload items accounted for more than 80% of all examinations and tests, which means the uploaded data of examinations and tests have become more complete.

Medical Information Is Fully Uploaded in Real Time

As of December 2020, a total of 27,353 medical institutions were participating in the Plan of Querying in Real Time (participation rate 93%), including 470 hospitals (participation rate 100%) and 19,769 clinics (participation rate 94%); since the Plan of Querying in Real Time was launched in 2015, there have been 3.4 billion examinations and test results and 68.07 million medical images uploaded by medical institutions as of December 2020; the hospital upload rate of examinations, test results, and medical images in 24 h also increased year by year, and exceeded 80% by 2020 (Figs. 10.4 and 10.5).

Fig. 10.4

Trend of real-time upload rate of examination and test results (2018Q3–2020Q4)

Fig. 10.5

Trend of real-time upload rate of medical images (2018Q3–2020Q4)

Strengthening the Uploading of Medical Information and the Integration of Claims for Reimbursement

In the current review practice, fraudulence has been found in that some hospitals submitted a claim without providing corresponding medical services or duplicated claims. According to the claims data of medical examinations, tests, and medical images combined with the uploaded examination and test results and medical images, it was found that the upload rate of clinics was low (Tables 10.2, 10.3 and Figs. 10.6, 10.7, 10.8, and 10.9).

Table 10.2 Implementation status of plan of querying in real time in 2020—examination and test results

Table 10.3 Implementation status of plan of querying in real time in 2020—medical images

Fig. 10.6

Case statistics of claimed and uploaded examination and test results in the Plan of Querying in Real Time in 2020

Fig. 10.7

Relative value unit statistics of claimed and uploaded examination and test results in the Plan of Querying in Real Time in 2020

Fig. 10.8

Case statistics of claimed and uploaded medical images in the Plan of Querying in Real Time in 2020

Fig. 10.9

Relative value unit statistics of claimed and uploaded medical images in the Plan of Querying in Real Time in 2020

Broadly speaking, the complete claims data submitted to the NHIA by medical institutions should include the claim for reimbursement and the implementation data of providing medical services, such as results and reports of examinations and test and medical images (including reports). To meet the principles of claiming according to the medical services actually provided, it is necessary to upload the relevant report in the medical process. The NHIA will first review the cases that have been claimed, but the examination and test results have not been uploaded to understand in depth whether there is any fraudulence that medical institutions submitted the claim to the NHIA without providing corresponding medical services.

However, medical institutions now upload the medical information following the Plan of Querying in Real Time, which is only an incentive plan. To achieve the goal of fully uploading, the NHIA reviews laws and payment regulations of examinations and tests of the National Health Insurance, such as “Regulations Governing the Production and Issuance of the NHI Card and Data Storage,” to make laws and regulations more comprehensive. Eventually, provided that medical services correspond with the claims data, the uploaded data will also correspond to the claims data.

Strengthening the Connection Between the Contracted Institution Hospital Information System and the National Health Insurance Information System—Usage of the Medical Visit Identifier and Timely Upload Improves Data Accuracy

To comply with the trend toward cloud services and big data applications, the NHIA integrates the monthly medical claims data, the daily uploaded medical visit data of the NHI card, and others to establish a “people-centered” database. In 2013, the “NHI PharmaCloud System” was built, and its scope was expanded in 2015 to become the “National Health Insurance MediCloud System (NHI MediCloud System).” Since 2017, the function of uploading and sharing medical images, such as CT and MRI, was added. The system could be accessed online by clinicians to understand the patient’s medical history as a basis for prescribing drugs or inspections. In addition to safeguarding medication safety for patients, it can also save unnecessary costs of examinations and tests. The NHI MediCloud System and the Hospital Information System (HIS) are linked closely through the NHI Application Programming Interfaces (APIs) and a VPN. The contracted medical institutions and the data on the NHI MediCloud System are promptly connected, and the information is shared across institutions. The interaction between the two is thus more closely linked.

However, there are still the following issues that may affect the effectiveness of the NHI Big Data applications in practice. According to Article 10 of the “Regulations Governing the Production and Issuance of the National Health Insurance IC Card and Data Storage”: the contracted medical institutions shall upload the medical records within 24 h after they have been registered on the NHI IC cards to the insurer for future reference. Most institutions upload batches daily, but some do not know how to correct or write off prescriptions after uploading the medical records. As a result, the information on the NHI MediCloud System might be incorrect, or people might find abnormal medical records through the My Health Bank System. Moreover, the information systems of the NHI such as the NHI MediCloud System, e-Referral Platform, and the NHI Express App have to connect the medical service items (such as examinations and tests, drug dispensing, medical images) received by the public at the time of medical treatment, but some data cannot be connected owing to the inconsistency of the primary key value. Other related businesses in the NHIA, such as comparing the medical claims data between the clinic that released the prescription and the dispensing pharmacy, or other statistical analysis applications on personal medical visits, may also encounter the above situation, resulting in a decrease in data accuracy. In addition, if the insured person reissues a prescription at the institution owing to a change in medical condition or claims that the prescription is lost, and then holds the original prescription (or holds the printed prescription) to the pharmacy for repeated dispensing, the pharmacy cannot verify from the NHI MediCloud System regardless of whether or not the prescription has been canceled (prescription validity).

To improve the connection with the information of the institution’s HIS and the quality and safety of medical care for people, the NHIA has developed enhanced measures for the timeliness and accuracy of medical data. The instructions are as follows:

• 1. Functional improvements of the information system for the NHIA

  • (a) Timeliness: the relevant data flow and system structure have been adjusted to receive the medical visit data of the NHI IC card. The system adopts parallel technology to do data checking, and the checked data will be synchronized to the NHI MediCloud System timely.

  • (b) Accuracy: the NHIA developed the correcting operation for the medical visit data of the NHI IC card, in response to the situations that contacted the NHIA regional division for correcting the uploaded data, to improve the accuracy of the sharing information such as the My Health Bank System or the NHI MediCloud System.

  • (c) Establishing the mechanism of the “medical visit identifier”: to facilitate the concatenation of individual medical information and confirm the validity of prescriptions.

  • (d) Planning to build a timely uploading mechanism of the NHI IC card medical visit data for canceled prescriptions: when pharmacies are dispensing, they can check whether or not the prescriptions have been canceled on the NHI MediCloud System.

• 2. The strengthening measures planned for the contracted institutions

  • (a) The clinics provide a timely upload of medical treatment information: the NHIA coaches the institutions to upload the medical information to the NHIA within 6–8 h after providing medical services, speeding up the data flow.

  • (b) Simplify the correction operation of the uploaded NHI IC card medical visit data: for data with the same primary key value, adjust the process to improve the accuracy of the NHI MediCloud System data.

  • (c) Establish a medical visit-identified mechanism (Fig. 10.10):

    • (i) Every time people seek medical care, the HIS of the institution contacts the NHIA’s card reader control software for a medical visit identifier generated by a special calculation function.

    • (ii) The “medical visit identifier” is a unique 20-digit code consisting of the institution code, time code, and personal ID for an individual medical visit. It can be printed as a bar code if necessary so that a bar code scanner can acquire the medical information instead of manual input.

    • (iii) After people receive medical services, the medical visit identifier with the combination of the medical visit data of the NHI IC card and the medical claim data is uploaded to the NHIA to improve the accuracy of subsequent data concatenation.

  • (d) The timely upload and cancelation of the prescription mechanism for the institutions: upload the contents of the prescription with the medical visit data of the NHI card for the pharmacy to confirm the prescription validity. If a prescription is delivered during the medical visit, the medical visit data of the NHI card must be uploaded within a certain period for the pharmacy to query on the NHI MediCloud System to check whether the prescription can be dispensed (Fig. 10.11).

Fig. 10.10

The principle of the medical visit identifier production system and the providing method

Fig. 10.11

Both the prescribing site and the dispensing site confirm the validity of the prescription by the “medical visit identifier”

Conclusion

Under the government’s facilitation of the Digital Nation and Innovative Economic Development Program, emerging technologies are continuously transforming the healthcare industry. The NHI Big Data is an important national asset supporting the business advancement of the NHI, health and medical management decisions, and the value-added applications in the biomedical industry with the support of legislation.

“The value of data begins with integrity and precision.” Accumulated for more than 27 years, the rich and comprehensive database of the NHI consists of the long-term joint efforts of the NHIA, institutions, medical information and communication vendors, and other partners. Therefore, the NHIA will strive to strengthen the connection between the HIS of the institutions and the NHI information to improve data accuracy and timeliness, to enhance its applicability in the My Health Bank System for people, the NHI MediCloud System for medical institutions, and AI reviews. The NHIA will also continue to provide medical facilities with incentives to upload examination and test data in real time and bundle the uploaded data with reimbursement to secure the integrity of the dataset. It is hoped that, utilized properly, the information system will help the NHIA to achieve the goal of increasing medical efficiency, reducing medical expenditure, developing smart health care, and improving the health of all residents.