Application of a single sampling plan for auditing medical-claim payments made by Taiwan National Health Insurance.
National Health Insurance (NHI) has been implemented in Taiwan for nearly a decade. Owing to growing demand for medical-care, effective sampling auditing is a key factor in obtaining reasonably priced medical-care services. This investigation proposes a conceptual framework "medical-claim payment auditing (MCPA) procedure" based on the "Military Standard 105E (MIL-STD-105E) single sampling plan" for establishing an objective criterion for making medical-claim payments fairly. The MCPA procedure contributes to the following: (1) meeting international standards of sampling technology; (2) reducing the sampling ratio and consequently auditing costs; and (3) encouraging healthcare providers to honestly apply their medical-claim payments thus avoid wasting medical resources.
Fu
Hwai-Hui
HH
Fortune Institute of Technology at Kaohsiung, Taiwan, Business Administration, 3F-5, 10, ANSHYR Road, Kaohsiung 803, Taiwan. wuu.fuu@msa.hinet.net
Tsai
Hsien-Tang
HT
Lin
Ching-Wei
CW
Wei
Duan
D
D005375:Financial Audit; D005102:Health Expenditures; D007345:Insurance Claim Review; D009313:National Health Programs; D012051:Reimbursement Mechanisms; D013624:Taiwan