The payment system has a great impact on the overall growth of medical expenses, the distribution of medical resources as well as medical efficiency and quality. To quickly integrate the existing civil service, labor, and farmers’ insurance system, the fee-for-service approach was adopted as the primary National Health Insurance (NHI) payment system at the beginning of its establishment. The content also elaborates the concept and operation mechanism of the global budget payment system and various supplemental payment methods in the NHI, such as case payment, per diem payment, pay-for-performance and Taiwan diagnosis-related groups (Tw-DRGs). The challenge of securing relative value units (RVUs) or RVU value to foster specific healthcare services is discussed in this chapter. The National Health Insurance Administration (NHIA) continues to revise the fee schedule to reflect technological progress, real clinical needs and reasonable rewards for health professionals. In this chapter, we introduce the process for the revision of the fee schedule and the integration of Health Technology Assessment (HTA) in decision-making. To close the inevitable budget gap, self-management of the global budget for each NHI district and payment department was designed to contain medical costs.
The big data generated by the National Health Insurance (NHI) medical information system is the most important asset that Taiwan possesses in promoting national digital policies. Hence, it is the NHI’s priority to maintain the quality of the dataset and its interoperability with healthcare facilities. This chapter presents the process for claiming medical expenses in detail and gives examples of how the National Health Insurance Administration (NHIA) proactively assists providers to submit accurate claims.Although most medical examination and test results, images, etc., are uploaded in a timely manner to the NHI medical information system, the NHIA plans to bundle the reimbursement to the provider with data upload to further its accuracy. The author explains the strategies applied to strengthen the connection between the hospital information system of contracted institutions and the National Health Insurance MediCloud System (NHI MediCloud System) to improve the accuracy of the data uploaded, such as medical visit identifier, instant upload, and the write-off mechanism.The long-term collaboration among the NHI, contracted institutions, and information system vendors is the key to guaranteeing the quality of the dataset.
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