全 民 健 康 保 險 年 報
National Health Insurance In Taiwan
2013-2014
ANNUAL REPORT
全民健保醫療服務案件之審查，在於審
查特約醫療院所提供之醫療服務項目、數量、
適當性及品質。平均一年門診申報量約
3.8
億
件，平均每日約
104
萬件，一年住院約
329
萬件，平均每日約
9
千件。基於人力及行政
成本考量，有關醫療服務審查大體可區分為
程序審查與專業審查；在工具面，亦大量運
用電腦科技與資料分析技術，並致力於發展
電腦醫令自動化審查及檔案分析等電腦輔助
審查系統以提升審查效率。
審查制度
The review of reimbursement claims filed by contracted
health care organizations involves screening the type, volume,
quality and appropriateness of medical services provided under
the insurance program. Every year, 380million reimbursement
claims on average are filed for outpatient visits (or 1.04million
per day) and about 3.29million claims (or about 9,000 per day)
are filed for inpatient care. Because of the massive volume of
claims, the review process follows two tracks: a procedural
review track that is fully automated and a professional review
track that involves peer reviews. Computer technology is
used in conducting both types of reviews, but especially the
procedural review, which relies on profile analysis based
on specific medical criteria in conducting automated audits,
improving the efficiency of claims reviews.
Claims ReviewSystem