全 民 健 康 保 險 年 報
National Health Insurance In Taiwan
2013-2014
ANNUAL REPORT
The huge volume of claims makes it impossible to screen
each and every one of them manually. Instead, claims are
randomly selected, which involves randomly pulling claims
and related medical records and sending them to medical
experts for review. If the amounts claimed by a medical
institution are reduced by a certain percentage across the
sampling after peer reviews, the institution’s total claims will
be reduced automatically by the same percentage. This is the
most important function of the professional reviews of medical
expense claims.
Since 2007, the random checks have not only involved
reviewing a fixed percentage of reimbursement claims but
also profiling a certain percentage of patients, primarily to
enable the experts conducting the reviews to see complete
patient information and help them better identify what the
reviews’ main points of emphasis should be, making the
process more relevant. Since the global budget system’s
phase-in beginning in 1998, the NHIAhas also commissioned
medical associations to handle some of the professional
reviews and established management guidelines on recruiting
experts to conduct the reviews. In addition, the NHIA and the
independent agencies have developed a mechanism capable of
jointlymanaging the professional reviews in every region.
另外，由於申報案件甚鉅，健保署於專
業審查時採隨機抽樣審查，即以抽樣方式調
閱部分病歷送請審查醫藥專家審查，透過以
樣本的核減率按比例回推至全部母體案件進
行核減的作業方式，是醫療費用事後專業審
查的最主要作業。自
2007
年起，隨機抽樣方
式除原有以案件比率的作業方式外，另新增
以病人數比例計算的論人隨機抽樣審查作業
方式，主要目的是為了能讓審查醫藥專家看
到病人完整的就醫內容，更能掌握審查重點，
提升審查的適切性。總額支付制度自
1998
年
起陸續實施後，健保署配套進行專業自主事
務的勞務委託，另訂定審查醫藥專家之遴聘
管理方式，並逐步與受託單位建立了各分區
專業審查共同管理的機制。