Research On Risk Management Of Short - Term Health Insurance Claims In

With the gradual processing of China’s medical reformation, medical insurance system is maturing and commercial health insurance get a big opportunities to develop. Especially in the21st century, with aging process acceleration, medical technology rapid development, residents’growing income and people’s higher requirement in health care consumption,which caused the sharp increase of medical care expense. Because of the the increasingly fierce competition in insurance, in short-term health insurance "Attention business、Not value claims" in different degrees, unstandard claims management, blind pursuit of market share and premium growth, ignoring the management benefit, allowing unhealthy customer to get insurance are all exists. The annual medical care expenses increases every year and the loss ratios of health care expense stays high, also the claim risk management of insurance cannot reach the demand of current market demand, these two issues are becoming real difficulties for each insurance company. Therefore, health claim risk management has becoming one of the important aspects that influences the management of insurance industry.This essey comprehensively summed up the problems in company’s claim risk control especially cost control of medical insurance by investigating the present situation of medical insurance of companyA. By solving these problems with advanced claim risk management experience aims to establish a relatively integrated, systematic, suitable and practical risk control system based on the actual situation of the company, which can the operating risk of an enterprise.frist, analyze the management of risks and external demand and the health care providers of medical services and social risk factors within the insurance claims process. Outline the theory development of health insurance claims for domestic and international risk management.Then, describe the operating conditions of short-term health insurance in the region of A Company, detail the health insurance status short-term health insurance claims, risk management and claims analysis of the problems in A company. Then, compare the related indexes of insured patients and patients at one’s own expenses of medical expenses, further confirms that the controlling of medical expense’s irreasonable growth is the key to reduce claim risk effectively. For A company health insurance medical treatment cost analysis of relevant factors and build multi-factor regression equation, this paper expounds the problems of claims in health insurance medical expenses.Finally, in view of the above questions, strengthen A company’s internal employee professional ethics construction, foster the good enterprise culture, establish perfect the internal training and performance evaluation mechanism, standard health insurance claims process, improve the company internal claim risk management level. Implement health insurance company and medical institutions, continuously explore new claims means, try new fee payment of medical service process, effective control; Establish the reasonable cost sharing model, enhances the insurant saving consciousness, control medical expenses not reasonable growth, fundamentally solve the health insurance claim risk management problems of domestic, hoping to offer reference to health insurance companies which can be helpful to short-term health insurance development.