Stabilization

Enhancement
Expansion
Introduction
Portal system

Establishment of DW system
DW, OLAP, Data Mining system
Establishment of National Health
Insurance Data Network
Host System Client/Server
Establishment of Health Insurance
Review & Assessment Service
Development of Review &

Assessment system

Establishment of DUR, medical

reimbursement claim portal

system
Control system for headquarters
and branches
Information security system

Establish next generation

Review & Assessment system
Implement ICT Service
Management system EA, ISO

Merge information systems of

headquarters and braches
Green, Expand Smart ICT

Current status

About 86,980
providers

1.45 billion claims

a year

USD 56 billion

Fast and accurate processing of large bulks of data

Requirements

Expansion of real-time services (DUR, etc.)

Reinforcement of personal information security, guarantee IT
system stability

Stable
management
of large scale
data system

Number of servers

UNIX servers: 160

x86 servers: 240

Data volume

1,887 TB

Number of programs

40,000

ICT employees

210 people

Collection
Health Care
Provider
Medical fee claims
Provider info
Data for assessment
Prescription and
Dispensing records

Store and Process

Utilization
NHIS

EDI

Portal System

ReviewAssessment System

Utilization

WEB

Review Assessment
MCPoS

Review
System

Assessment
System

MoHW

Pharmaceuticals

Record of
drug supply

WEB

Providers
Portal

Portal for
the public

DUR

Provider
management
system

On-Site Development of
Investigation benefit standard
and policy

the Korea
Veterans
Welfare
Corporate

Data analysis system

Provider

Treatment

MFDS
Center for
connecting
4 major
insurances

Dedicated
line

Medical device info

Eligibility check
Adjustment check

DUR

DW
system

Data mining

Connecting
system
Local
governments

Operation of remote ICT center (integrated DR center for MoHW)

HIRA
Review
system

Portal
system

Disaster Recovery Center

DUR
system

File duplication solution

DR-review
system

DR-portal
system

Duplication of service programs and file systems

Dedicated network

Real-time data duplication

Management
storage

Storage duplication solution

DR storage

Uninterrupted service even in the event of a catastrophe.

- Real time data duplication
- Conduct regular simulation trainings twice a year

DR-DUR
system

Security management of every stage of information system

PC
security
(1st stage)

External user

DDoS Defense
system

Network
security
(2nd stage)

Server
security
(3rd stage)

DB security
(4th stage)

Access control
Firewall

Database

Intrusion route
Server OS security
Application program security

DB encryption

Firewall
Invasion prevention system
DDoS defense system

Internal user

Stages

Anti-virus
File encryption (DRM)

Security measures

Stage 1- PC security

User authentication, central management of vaccine, document security [DRM) and flash
memory access control

Stage 2 - Network security

Firewall and intrusion blocking system, web firewall and DDoS defense system, VPN

Stage 3 - Server security

Server security (SecureOS), access control, integrated access record management

system

Stage 4 - DB security

DB encryption (personal information), DB access control and access record management

International Patent

ISO9001

Electronic Medical Claim Review, Business Method

07 Republic of South Africa
08 Japan
09 Singapore, Australia
10 Vietnam
12 U.S

05 EDI review system

06 DW and Mining system
07 IT system (including web portal service)
10 KPIS system
12 DUR and VOC system
14 ISO20000 expected (IT Service Management), forward

Data Quality Certification by Korea Database Agency

11 DQC-M(Management)
11, 12 DQC-V(Value) DW Platinum Class(99.99%)

Limitation of paper base review

- Missing cases occur

- Restrictions on consistency and reliability on examinational results

- Difficulty of statistical productions
- Other various limitations (Labor cost, delay of examinations)

E-claims Agencies
01: 64% 06: 90%11: 99%
* EDI; Electronic data interchange

After introduction of EDI,

all service provisions were able to be claimed

efforts to expand EDI introduction

- Sent EDI claims promotion information

- Initially, the opening fees were waived and usage fees were reduced
- Medical and pharmaceutical association meetings
- Contributing associations and medical institutions were provided a reward

Benefits of Electronic Claims

(Medical Institution)
- Claims functions were dramatically simplified:
claims specification form output, binding, transfer, etc.
- Medical fee payment period shortened: 40 days 15 days
- Specialized review result checking possible (EDI)
- Time and cost savings (Reduced labor costs, etc.)
- Post-calculation and number of formal objection functions
reduced
(HIRA)
- Review expertise and scientific
- review payment system improvement
- Business process speed, accuracy, and efficiency increased
- External input and claims specification form output cost, reduced
1
4

Web claims form strengths

- Medical fee claims fee for free: Using regular internet, transit costs reduced
(each individual medical institution 136-16,300USD annually)
- Transmission capacity limitations expanded (80MB500MB),
visual materials can be submitted easier
- Using HIRAs claims error pre-check service, claims returned significantly
reduced
- By simplifying claims procedure, the processing speed increased more
than 3 times
- From claims steps until review determining, the whole process was handled
in one stop
1
5

1
Healthcare
Provider

Diskette

EDI

MCPoS(Web Portal)

Portal
Simple error
checkup

Claim Submission
Processing

Benefit Standard

Data Review

Screen Review

Review
Standard

Prescription Index

DW System
4

Review Closing

Review Decision

5
Payment Information
Storage

Construction of
Payment Information

National Health
Insurance Service

EDW
Mart

Notification of
Review Results

Eligibility
Confirmation

Appeal Management
Appeals

Healthcare
Provider

Appeal Result Notification

Quality Assessment result
notification

Re-Evaluation Decision

Evaluation of
Quality Assessment

Calculation File
Construction

Statistic Analysis

1) Claim System

0.3%

2) Review System

95.4%

4.3%

 6 Stages of the Automatic Data Processing

Stage 1

Stage 2

Stage 3

Stage 4

Stage 5

Stage 6

(Writing CK)

(Automatic CK)

(Drug Inspection)

(Benefit-Std CK)

(Disease-specific CK)

(FLEX CK)

Verifies against

Verifies drug

Reviews

Drug interaction

Verifies the

Verifies codes,

required field

unit-prices,

guidelines

interaction

simple and

& overlapping

(omission, error, or

calculations, etc.

(Governmental

& duplication

frequent disease

prescription

duplication, etc.).

regulations, etc.)
-A (error in unit price)

Returns claims
that more than
30% of fields
are errors or

-F (document
omission)

- Reviews claims
using algorithms

-K (coding error)

based on the

-Etc.

guidelines

with algorithms

check-up
Check for cases

- Contraindication

without human

* Drug-Drug

which exceeds

input

one-day or total

* Drug-Age
(Children)
* Pregnancy

drug benefit caps

- Drug approval
information

- Detects multiple

- Benefit guidelines

by drug code
- Contraindication
* Co-medication,

missing to

prescriptions with

providers

low dosage

- Overlapping presc.

prescriptions.

- Check for cases by

- Duplication

age, pregnancy

drug code(one-day,
total benefit caps)

CK: Checkup

 After passing through the computerized checkup process, some claims are sent to
review department for manual staff review. Review process is finalized after staff

review, benefit adjustment and closing.

Distribution

Check

Review

Closing

Before starting the

According to the

Finalized cases are

Distribute benefit

manual review, the

review standard and

ready to turn the

claims data to

staff check

guideline, the staff

status to result

review staff

providers trend

review claims and

confirmed

and electronic

finalize results

(Electronic process

checkup results

closing)

Definition

Data
configuration

System
utilization

A decision making supporting system which encompasses nationwide

clinical information, drug supply and distribution information, and other
related data in order to produce fast and accurate national statistics.

Benefit review and assessment data (360TB)

Drug distribution data (Production, import, supply, purchase, consumption)
Healthcare providers resource information such as personnel, equipment,
facility and etc.
Benefit standards (drug price, fee schedule, medical material price, etc.)

Government: basic data for health care policy making

Public: reference on hospitals, pharmacies, medical fees, drug price,
medical resources, etc.
Provider: DUR, assessment results, incentive provision details, etc.
Media: current state of public health, etc.

Drill Down

Drill Up

Unit: 100 million

TOTAL

2007

2008

2009

2010

2011

2012

2013

2014

2015

117

10

12

13

13

13

14

14

14

13

Medical
Treatment Data

350

29

34

37

38

39

42

42

44

35

Dispensing
Data

401

41

41

44

45

45

46

45

47

47

Claims Data

Claims data: information for benefit claim patient, disease code, amount of benefit, etc.
Medical treatment data: received treatment (consultation, treatment, surgery, etc.)
Dispensing data: dispensed drugs from pharmacies

 Government branches: basic data for policy making and review

National Statistics Office: national level statistics data support
Academic institutions, universities: clinical analysis, medical cost, drug consumption survey, etc.

Private usage
Healthcare Provider

Insured

DW System

Media (statistics,
certain disease, etc.)

Improving Quality
Web Portal for Claims
Quality Assessment

Cost Savings

Review System
Data Warehouse
Assessment
System

R&D Support

Portal for
healthcare providers
Hospital profile
system

Prescription
data via DUR

Concurrent Check
before filling the
prescription

Policy Making

Data Mining

DUR-Portal

Fraud Detection

Safety &
Convenience

MFDS DB

KPIS

KPIS-Portal

National
Drug
Management