JP2007323462A - Third party compensation work management system - Google Patents

Abstract

<P>PROBLEM TO BE SOLVED: To provide a compensation work management system for traffic accidents for restoring the health of national health insurance finance by collating the traffic accident dispatch records of the police and fire departments, etc., with bill medical information submitted next month by sharing the records in an information network including insurers, confirming that it is an insurable accident by an automobile, checking the presence of "10. third" description and thereby utilizing them for the number of cases of compensation work requests to the Federation of National Health Insurance Organizations and the contents of the cases, etc. <P>SOLUTION: The computer system (1-6) of at least one organization receives medical fee receipts from the computer system (6) of the Federation of National Health Insurance Organizations of all prefectures and confirms the presence of "10. third" description. <P>COPYRIGHT: (C)2008,JPO&INPIT

Description

  The present invention relates to a reimbursement office management system for providing medical insurance benefits against a traffic accident.

  For medical insurance benefits due to frequent traffic accidents, the national health insurance and social insurance insurers make primary replacement payments, which are later settled by automobile liability insurance and returned to the insurer.

  However, due to the rapid increase in the number of accidents caused by automobiles in recent years, the number of reimbursement work according to the provisions of Article 67 of the Health Insurance Act (including cases where it is applied mutatis mutandis in Article 69-2) or Article 64, Paragraph 1 of the National Health Insurance Act has increased. However, the current situation is that insurers (municipalities) cannot respond sufficiently. For this reason, the National Federation of Health Insurance Organizations in the prefecture handles reimbursement work on behalf of insurers.

  Along with this, the insurer has requested medical institutions to write “10. Third” in the special remarks column of the medical fee remuneration statement (receipt) to indicate that it is an automobile accident. It is pointed out that there are many medical institutions that submit a receipt without filling in “10.

  As a result, insurers who are primary replacements until the settlement of non-life insurance will be paid in full by National Health Insurance because there is no “10. It is raising the sense of crisis that it will cause great damage to people.

  The subject of the present invention is to share the record of traffic accidents such as police, firefighting, etc. in the information network including the insurer, so that it matches the receipt information submitted the next month and confirms that it is an insurance accident caused by a car. In addition, by checking the presence or absence of “10. Third” labeling, it will be used for the number of cases of compensation commissioned to the National Federation and the contents of the cases, etc. Is to provide a reimbursement office management system.

  This problem is solved by the traffic accident compensation management system according to claim 1.

-Since "10. Third" can be confirmed through a computer, management becomes easy.
・ Easy to check for unauthorized charges.
・ It can be used for teaching medical institutions.

  Hereinafter, the traffic accident compensation management system of the present invention will be described in detail with reference to the drawings.

  FIG. 1 shows a traffic accident compensation management system according to the present invention.

  When a National Health Insurance insured causes a traffic accident, the police and, if necessary, firefighting and other agencies are dispatched to the scene. The police verify the accident site and if there is an injured person, an ambulance at the fire department transports the injured person to a medical institution. The police will then report details about the accident to the insurer in the municipality concerned. In addition, the medical institution prepares a receipt and requests it from the National Health Insurance Federation. The National Health Insurance Association requests and accepts the receipt.

FIG. 2 shows the contents of the reimbursement paperwork between the National Health Insurance Federation and the insurer. The flow is explained below:
(1) Reception Check the description and details of the attached documents.
(2) Completing the ledger Fill in the necessary information and indicate the progress of negotiations based on the attached documents.
(3) Notification of trust Notice to the non-life insurance company, etc. that the insurer has been entrusted with billing work.
(4) Attorney Consultation Consultation regarding negligence ratios, etc., for contracted projects.
(5) Negotiations Negotiate with non-life insurance companies, etc. to determine negligence allocation.
(6) Determination of compensation amount
When the negligence ratio is determined, the insurer is notified of the reimbursement amount decision.
(7) Determination of reimbursement amount Based on the determination (inquiry) of the reimbursement amount, a response document is received from the insurer.
(8) Request procedure After obtaining a response from the insurer, etc., request the insurance company, etc. together with the relevant documents such as a receipt. (9) Storage The invoiced amount is transferred from the non-life insurance company to the National Health Insurance Federation.
(10) Creation of storage breakdown Notify the insurer, etc. with a storage breakdown.
(11) Remittance After the storage breakdown is shipped, it is transferred to the designated account of the insurer.
(12) Completion Send a completion notice to the insurer.

  FIG. 3 shows an example of a computer system provided in each organization for the above exchange.

  The computer 9 can communicate with computers 9 of other organizations through a telephone line (Internet) 8. A database 10 that stores the aggregated data, a display 11 that displays the data, and a printer 12 that prints the data are connected to the computer 9.

  This structure of the computer system allows the insurer to facilitate the “10. Third” confirmation, and therefore facilitates checking of fraudulent claims.

  The third-party compensation office management system of the present invention can also be applied to long-term care insurance.

1 shows a traffic accident compensation management system according to the present invention. Shows the procedure for reimbursement. 1 shows a computer system.

Explanation of symbols

1 Computer system at police station 2 Computer system at fire station 3 Computer system at other institutions 4 Computer system at insurers 5 Computer system at medical institutions 6 Computer system at the Prefectural National Health Insurance Association 7 Computer system at non-life insurance company 8 Telephone line ( the Internet)
9 Computer 10 Database 11 Display (Display means)
12 Printer (display means)

Claims (3)

In the reimbursement office management system that provides medical insurance benefits for traffic accidents through the telephone line through the computer system (1-6) of each institution,
The computer system (1-6) of at least one institution receives the medical remuneration statement from the computer system (6) of the Prefectural National Health Insurance Federation and confirms whether or not “10. Third” is displayed. Reward office management system to do. The reimbursement office management according to claim 1, characterized in that the computer system (1-6) is a computer (9), a database (10) connected to the computer (9) and at least one display means. system. 3. The reimbursement office management system according to claim 2, wherein the display means is a display (11) and / or a printer (12).

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