Research On The Integration Of Medical Insurance And Commercial Health Insurance Claims For Urban And Rural Residents

The medical insurance system for urban and rural residents is a combination of new rural cooperative medical insurance and urban residents' basic medical insurance.Medical insurance for urban and rural residents is organized by the government to guide residents to participate voluntarily.This is a medical system that benefits Chinese residents.The development of medical insurance for urban and rural residents is not only directly related to the health and interests of all Chinese residents,but also important for coordinating urban and rural development and building a well-off society in an all-round way.Since the recovery of China's commercial medical insurance business in 1982,China's commercial health insurance premiums have grown rapidly and the product range is abundant.The four major insurance companies directly under the central government are the market leaders.The joint venture and joint-stock insurance companies fully participate in the market competition.China's commercial medical insurance presents a market situation with a lot of flowers.However,China's commercial medical insurance is still in the first stage of development,and it is very different from foreign developed countries.The biggest problem is the backwardness of the business model.The business model of health insurance means that health insurance can provide customers with health insurance products and services by any means or means,so that they can obtain health care,while commercial life insurance companies achieve the goal of maximizing profits.China's commercial health insurance business model is currently a "payment" business model,mainly using post-payment methods.From the perspective of countries with good global commercial health insurance,most commercial health insurance is provided by professional commercial health insurance companies,providing medical and sickness insurance services to consumers.In addition to products such as disability income insurance and long-term care insurance,it also works with health care organizations to control the growth of medical and health costs,provide medical services to clients,and participate in government health insurance plans.However,due to the different economic history and culture of the state and the medical insurance system,China's social basic medical insurance and commercial medical insurance systems have different starting and development processes.The joint development of the two is the basic guarantee for ensuring the efficiency and fairness ofthe entire medical security system.But the difference between the two processes from insurance to claims is obvious.How to coordinate and develop the two,establish and improve China's multi-level medical security system,and fundamentally solve the problem of "difficult to see a doctor" and "expensive medical treatment".From the perspective of public management,from top-level design to specific implementation rules,issues that need attention and discussion.This article contains seven parts.The first part is the introduction.The basic content of the research background,purpose,research significance and method is expounded.The second part is the research on the theory of the connection between urban and rural residents' medical insurance and commercial health insuranc,social medical insurance of urban workers medical insurance and urban and rural residents medical insurance claims,and the major diseases in commercial health insurance.The theory of claims for insurance,inpatient medical insurance and disability income insurance is elaborated,and the theory of claims integration is refined.The third part is case analysis.Through two specific cases,the claims process,claim amount and claims characteristics are compared and analyzed.The fourth part is the comparison of the two insurance claims policy.The specific policy of urban and rural residents' medical insurance in a county in Jiangxi in 2019 and the commercial health insurance's claims policy are compared.It can be seen that the claims of urban and rural residents' medical insurance are biased towards the general public.Being able to participate universally in health care can reduce the burden when medical risks occur.The claims policy of commercial health insurance is strictly enforced according to the insurance contract concluded.The claim line is determined according to the specific amount of insurance,which can complement the medical insurance for urban and rural residents.The fifth part of the urban and rural residents medical insurance and commercial health insurance claims convergence problems and elaborate.Through the case analysis,we can know that the problem of claims integration is mainly in the claims process and standards.The reason for the analysis is that the insurance institutions and the coverage of the two insurances make the connection of claims difficult.The sixth part is to learn from some foreign experiences,mainly for the American model of the commercial health insurance claims payment system,the Canadian model of the claims coverage system and the German model of claims innovation integration.The seventh part is the conclusion.It proposes to improve the integration of medical insurance for urban and rural residents and commercial health insurance claims.From the same claim standard,adjust the listof essential drugs on schedule,strengthen the management and training of adjustment personnel,and promote electronic claims.Through the case in the claim process integration,this paper puts forward three ways to explore the establishment of direct claim mode.The results of the study:(1)Through the case analysis,it is found that the urban and rural residents' medical insurance claims have the deductible line,the capping line and the self-paying amount.The other part is the part of medical insurance reimbursement.The commercial health insurance is divided into fixed compensation and actual payment.The corresponding proportion of medical expenses is compensated,and for the cost-compensated insurance,the prime compensation amount of all medical insurance will not exceed the total amount of medical expenses.(2)Through the comparison of claims policy,the claims for medical insurance for urban and rural residents are biased towards allowing the general public to participate in medical insurance.In addition to being a supplement to medical expenses,commercial health insurance also has a fixed amount for serious illness to compensate for illness.Income and subsequent rehabilitation costs.Research conclusions:(1)In order to have better medical security,urban and rural residents' medical insurance and commercial health insurance cannot substitute each other,but complement each other.(2)Urban and rural residents' medical insurance and commercial health insurance have difficulties in the integration of claims processing.The reason is that medical insurance,hospitals and commercial insurance companies belong to different systems,system barriers are difficult to break,and platforms are difficult to integrate.(3)Urban and rural residents' medical insurance and commercial health insurance have difficulties in the integration of claims standards because commercial insurance companies have commercial competitions at the time,and urban and rural residents' medical insurance cannot meet the requirements of commercial insurance companies' claims standards.People have the mentality of using the disease to“profit” and it is difficult to prevent moral hazard.(4)According to the comparison of the medical insurance systems of the United States,Canada and Germany,the authors can draw on the American model in the payment system,and can learn from the increase in the coverage of claims.The German model can be used in the innovation of claims.(5)Based on the problems found,the author proposes a proposal to actively integrate the integration of urban and rural residents' medical insurance and commercial health insurance claims.Including unified claims standards,regular adjustment ofmedical insurance drug list,strengthen the management of adjustment personnel,and promote electronic claims.(6)It is recommended to establish a direct compensation model,which can be supported by cooperation with third parties,development of comprehensive medical care,and construction of systems capable of supporting various platforms.At the same time,it can also strengthen the professional operation of commercial health insurance companies,making claims coverage more comprehensive.