Research On Health Insurance Risk Control Based On Insurance Company 's Claim

With the advancement of economic development, medical technology, enhancethe quality of life of people but also increasingly concerned about their health, beganto pursue a higher level of medical services. But rising health care costs increased thepeople’s economic burden. Health insurance as an effective tool for the transfer anddispersion of health risks in recent years by a growing concern. According to theexperience of Western countries, led by either the private or the American model ofthe British welfare-oriented country, the development of commercial health insurancesystem for the improvement of health care, social security system has played animportant role.But China’s commercial health insurance there are many problems in the courseof business. The scale of its operations in the entire insurance market share is stillrelatively low, there is a wide gap with developed countries. The operating mode ofthe lack of professionalism, lack of core technology and professional personnel, norcan learn from the successful experience. Especially with the expansion of the growthof medical costs and insurance-scale, commercial health insurance companies facesevere operational risks, the concentrated expression of the high loss ratios and moralhazard, reflecting commercial health insurance companies lack effective means of riskcontrol, especially on the matter of risk and control risk afterwards.Moral hazard and ensure the premium system is the main matter, after theformation of risk. Interventional medical institutions so that the insurance companyresident in a passive position in claims and claims in excess medical insurancecompany makes the payment amount is often not consistent with the insured expected,easy to produce claims disputes, compensation cost increases. Ensure that the riskpremium system is the main reason for the formation of the post. In the long-termhealth insurance business process, with increasing age of the insured, the incidence ofthe disease every year to change, when the lack of pricing happens, if not promptlyadjust premiums would lead to a vicious cycle, is not conducive to a stable long termhealth insurance.From the perspective of commercial health insurance claims, discusses effectivematter, after the risk control methods to improve business health insurance companiescontrol the level of risk as the goal, efforts to reduce payment costs and improveclaims efficiency and improve service quality. I do against the risk to control moral hazard as a starting point, the use of game theory and mathematical statistics todetermine the main factors influencing the amount of the payment, the insurancecompanies and medical institutions to explore win-win cooperation model, and fromboth macro and micro aspects of improved health overhead costs of dynamicmonitoring system. For post-exposure, the author of the long-term critical illnessinsurance, for example, the use of scenario simulation method, actuarial theory todetermine the premium adjustment of the critical point, the preliminary design of theadjustable rate mechanism.Combined with the new risk control methods, the author based on China’s actualsituation, make recommendations on health insurance claims specialized constructionand information technology, and design patterns independent claims adjustersparticipating institutions. I believe that the policy should support, personnel training,data detection, claims to improve the quality and other aspects of risk management.This article is divided into four parts:The first part, the actual use of commercial health insurance claims data,summarize the reasons for the high loss ratio to determine the main direction of riskcontrol.The second part of the insurance for medical expenses insurance market,combined with foreign experience, discussed cooperation for China’s medicalinsurance (medical institutions and insurance companies) mode. On claims data wereanalyzed to determine the risk factors, risk control and give suggestions to improvethe dynamic monitoring system of medical expenses.The third part, for the long-term health insurance, the premium adjustmentmechanism design. The key adjustment mechanism design premium rate adjustmentis to find the critical point. In this paper, the actual data of China’s insuranceoperations, the establishment of a cash flow model to study the critical points rateadjustment and proposed premium adjustment strategy.The fourth part, combined with China’s commercial health insurance companyclaims the status of risk control, to improve claims management and risk control asthe goal, give specific recommendations in the field of specialization, informationtechnology and so on.The main innovation of this article:1.A study of commercial health insurance risk control in advance of the mainfocus of risk control, namely underwriting control. Based on claims angles, research in this area is still relatively small.2.Traditional claim risk control measures gradually can not meet the needs ofinsurance companies, faced with higher loss ratio to ensure health insurancepremiums is not suitable for the market. This paper attempts to design premiumadjustment mechanism, so that the insurance company has a new control method forthe long-term health risk insurance.3.Independent claims adjusters agency proposed the establishment ofcommercial health insurance, and the preliminary design.