Study On The Realization Of Direct-Billing Claim Pattern For Commercial Health Insurance In China

Since the recovery of commercial health insurance of China in the early1990s, the development of it has been rapidly, occupying more than10%of the country’s life insurance market. The annual premium income of commercial health insurance also increased from￥3.65billion in1999to￥112.35billion in2013.However, look from the level of development of the insurance industry as a whole, the development of health insurance rate is far lower than the personal insurance overall growth. The development of commercial health insurance has met with many obstacles; one of the main restricting factors is the backward claims mode in our country. Internationally, many developed countries health insurance is to implement the direct billing service mode. That means the insurants do not need to pay cash to the hospital, and then go to the insurance company for claiming when they are under treatment, the medical service cost will be settled directly to hospitals by insurance company.In domestic, as various areas improve their own management information system of medical treatment insurance in recent years, the insured of basic medical insurance can at least enjoy the direct-billing service of medical treatment. However, take part in the commercial health insurance, the insured, after accepting medical treatment at the specified medical service institutions, they need to pay their full bills first, and then go to the insurance company with the proof of payment as well as the costs to insurance company claim for compensation. This afterwards pattern of claim is unable to meet the needs of the insured to direct medical expense settlement. One the one hand, the insured of Commercial health insurance do not enjoy the more high quality claim service, therefore, to a certain extent, affected the health insurance market demand. on the other hand, the insured need to collect related claim material, and then go to the insurance company claiming for compensation, which will make the insurant to be antipathetic, cause unnecessary claims disputes, so as to damage the interests of the insured and the insurance company. Therefore, if the insurance company wants to survive in the cracks and develop further under the background of the basic medical insurance takes efforts to achieve wider coverage, they need to transform claims service model to attract more consumers and improve the competitiveness of the commercial health insurance in the market. So the research about establishing direct-billing mode in commercial health insurance is of great significance.This paper starts with the analyzing about current problems of commercial health insurance claim pattern, and puts forward the necessity of adopting the direct-billing claim pattern in commercial health insurance in the future. Next, I will introduce and describe the direct-billing mode of social medical insurance in many developed countries and China, and summarize their successful experience. And then introduce China’s exploration practice about direct-billing mode in commercial health insurance, analysis of the current restriction factors of it. Finally, I will put forward suggestions about the construction of China’s commercial health insurance with direct-billing mode, and introduce the design of the framework of it. The main points and specific contents of this dissertation are as follows:The first chapter will mainly introduce the background, implications, contents and innovation of my research, and give a summary and induction of the research status of health claims related issues at home and abroad.The second chapter of this dissertation will give a description about the current situation of the direct-billing mode of commercial health insurance claim pattern in China. However, in the whole market, direct-billing claim service has not really been the main stream. Based on this, I will analyze the obstacles which encountered by the claim system via from the market environment, the demand of insurance and insurance suppliers three points of view.The third chapter will introduce the domestic and foreign mature medical insurance claims experience. The United States’commercial health insurance is the most mature insurance system in the world, and it cooperates with the Medicare, which forms medical institutions and insurance companies as a community of interests. The insurance company is able to be participated in the whole medical process, and serve the insured with direct-billing naturally. Germany is a country which takes the social medical insurance as the main part of its medical insurance system, takes commercial health insurance as complementary part; this model is similar to China’s current status. Germany creates a good environment for the development of direct-billing claim system through a series of preparations, such as the perfect law-making, the establishing of systems and measures. In the process of building our own commercial health insurance claim system in China, we should combine it with our own special national conditions and position, to build industry chain, or by other means, to build our own direct-billing claim system.The fourth chapter, combined with the actual situation of China at present, straight to the constraints which met by our building of direct-billing claim system mentioned in the second chapter, I will put forward some suggestions about how to establish our own direct-billing claim system for commercial health insurance from the policy and institutional level, the insurance company management level and system support level.In the last chapter, according to the actual situation of China at present, I will put forward to use EDC technology to build direct-billing claim system, analyze the requirements of the system, and establish the basic framework and core processes of it.