论中国商业健康保险直付理赔模式的实现

发布时间：2018-05-07 08:50

本文选题：健康保险 + 直付理赔　；参考：《西南财经大学》2014年硕士论文

【摘要】：自上世纪90年代初中国保险业恢复以来,中国商业健康险业务发展迅猛,占据了人身保险10%以上的市场份额。商业健康险全年保费收入从1999年的36.5亿元增加到了2013年的1123.5亿元。尤其是2005年以后,人保健康、平安健康、昆仑健康、和谐健康等四家专门性健康保险公司的陆续成立,标志着中国商业健康险的发展进入了新的阶段。但是,从保险行业整体发展水平上看,商业健康保险的发展速度远低于人身保险整体增长速度。商业健康保险在发展过程中遇到了不少的阻碍,其中,落后的理赔模式是其发展的主要制约因素之一。在国际上,很多发达国家的健康保险都推行的是“直付式理赔(direct-billing)"服务模式。被保险人在医院就医过程中,不需要先向医院支付现金,再去保险公司理赔,医疗服务费用直接由保险公司对医院进行结算。在国内,随着近几年各地区完善了自身的医疗保险信息管理系统,基本医疗保险的参保人至少可以在本地区享受就医直付理赔服务,但是中国商业健康保险目前仍停留在“买单式理赔”的阶段。参加商业健康保险的被保险人,在指定的医疗服务机构就医后,需要先全额付款,然后带着付款凭证以及费用清单到保险公司索赔。这种事后的理赔模式,无法满足被保险人对医疗费用直接结算的需求,不能解决被保险人的燃眉之急。一方面,由于商业健康保险的参保人并没有享受到更优质的理赔服务,因而,在一定程度上影响了健康保险的市场需求。另一方面,买单理赔模式需要被保险人自己收集相关理赔材料,然后向保险公司索赔容易让被保险人产生反感情绪,造成不必要的理赔纠纷,从而损害被保险人和保险公司的利益因此,在目前基本医疗保险努力实现广覆盖的大环境下,对于保险公司来说,要想在夹缝之中求生存求发展,亟需转变理赔服务模式,以吸引更多的消费者,提高商业健康保险在市场上的竞争力。因此,直付理赔模式在商业健康险中的应用具有一定的研究价值。本文首先分析目前商业健康保险理赔模式存在问题,提出商业健康保险未来推行直付理赔模式的必要性；接下来介绍中国商业健康保险直付理赔模式的探索实践,分析目前制约中国商业健康保险直付理赔模式的因素；然后,对发达国家及中国社会医疗保险的直付理赔模式进行介绍、阐述,总结他们成功推行直付理赔模式的经验；最后,提出笔者对构建中国商业健康保险直付理赔模式的建议,并对直付理赔系统的框架设计进行了简要的介绍。具体内容和主要观点如下所述：第一章主要阐述了论文的选题背景、研究意义、研究目的,进而总结出中国商业健康保险发展直付理赔模式的必要性。另外,对国内外对健康险理赔相关问题的研究现状进行了总结与归纳,最后阐述了本论文的主要贡献与不足。第二章对中国商业健康险直付理赔模式的现状进行了阐述。许多保险公司在直付理赔服务方面做出了不少尝试,如中国人寿推出了“医保通”理赔系统、泰康人寿推出“健保通”理赔服务等,特别是在高端医疗保险方面,直付理赔保险产品持续火热。但是,就整个市场来看,直付理赔服务并未真正的成为主流。基于此,笔者从市场环境、保险需求方、保险供给方三个角度,对直付式理赔目前未能全面推广的原因,所遭遇到的障碍进行了分析探究。第三章介绍了国内外医疗保险成熟的直付理赔经验。第一,在市场环境方面,美国施行的是以商业健康保险为主的医疗保险模式,使得保险公司拥有较大市场份额,从而为直付理赔模式的推行提供了良好的市场环境。德国实行的是社会医疗保险为主,商业健康保险为辅的医疗模式。德国政府实施了一系列完善的法案、措施,为商业健康险能够实现直付理赔创造了良好的环境。第二,在经营模式方面,德国商业健康保险公司通过打造健康价值链,美国商业健康保险通过医保合作、第三方管理机构等经营模式,使得保险公司能够参与到医疗机构的医疗过程中,与医疗机构形成利益共同体,很好的解决了直付理赔所面临的信息不对称的障碍。第三,在信息系统方面,德国成立了“医疗赔付结算系统”研究中心,历时七年时间,建立了结算平台与结算系统。中国社会医疗保险借助与政府的大力推行,自21世纪初开始逐渐推行医疗保险信息系统,经过多年的建设,己初具规模,为直付理赔模式的推行奠定了良好的系统基础。第四章,结合中国目前的实际情况,针对第二章提出的直付理赔模式的制约因素,从政策与制度层面、保险公司经营层面及系统支撑层面,提出自己对商业健康保险直付理赔模式构建的几点建议：①完善相关法律法规；②引导专业化经营；③介入社会医疗保险；④引入第三方管理；⑤发展结合式医疗；⑥打造健康产业链；⑦搭建互联平台；⑧构建直付理赔系统。第五章,由于目前商业健康险公司尚未建立自己的直付理赔系统,因此,笔者根据中国目前的实际情况,提出利用EDC(Electronical Data Capture,电子数据捕获)技术来构建直付理赔系统,并对系统需求进行了分析,构架出系统基本框架和核心流程。本文的主要贡献主要表现在三个方面：第一,从保险市场环境、保险需求方以及保险供给方三个角度对制约中国健康险直付理赔模式发展的因素进行了分析。第二,根据中国目前的实际状况,从政策与制度、经营模式、系统支持三个层面,对商业健康险直付理赔模式的构建提出了自己的几点建议。第三,围绕EDC技术,提出健康险理赔直付系统的构建思路,主要对理赔资格验证、理赔审核和理赔结算子系统进行了分析。笔者所构建的直付理赔系统,相比于其他同类的系统,能够更好的把控风险。本文的不足表现在三个方面：第一,由于时间和能力有限,笔者没有详细的分析与阐述直付理赔模式的风险管理与风险控制。第二,未能对构建直付理赔模式所需成本和收益进行科学的比较分析。第三,本文只对健康险直付理赔系统进行了需求分析,而未能把系统细节给设计出来,且在直付理赔系统设计中未能考虑被保险人己经在其他保险公司处获得赔付的情况。
[Abstract]:Since the resumption of China's insurance industry in the early 90s of the last century, China's business health insurance business has developed rapidly, occupying more than 10% of the personal insurance market share. The annual premium income of commercial health insurance has increased from 3 billion 650 million yuan in 1999 to 112 billion 350 million yuan in 2013. Especially after 2005, people are healthy, safe and healthy, healthy and harmonious in Kunlun. The establishment of four specialized health insurance companies, such as Kang et al, marks the beginning of a new stage in the development of China's commercial health insurance.
However, from the overall development level of the insurance industry, the development speed of the commercial health insurance is far below the overall growth rate of personal insurance. The commercial health insurance has encountered many obstacles in the process of development. Among them, the backward claim model is one of the main constraints of its development. In the world, many developed countries have health insurance. In the process of hospitalization, the insured does not have to pay cash to the hospital first and then to the insurance company to settle the settlement. The cost of medical service is directly settled by the insurance company to the hospital. In China, the medical insurance information management system has been perfected in China in recent years. The insured persons of the basic medical insurance can at least enjoy the direct payment of the compensation service in the local area, but the Chinese commercial health insurance is still at the stage of "buying a single type claim". The insured who participates in the commercial health insurance should pay the full payment first and then take the payment voucher after the designated medical service institution is hospitalized. On the one hand, the insured person of commercial health insurance has not enjoyed the higher quality claim service and, to a certain extent, affects health insurance. On the other hand, it is necessary for the insurant to collect the relevant claim material by the insurant, and then to the insurance company, it is easy to cause the insurant to produce the repugnant emotion, and cause the unnecessary claim dispute, thus damaging the interests of the insured and the insurance company, so that the basic medical insurance is hard to realize the wide coverage at present. In the big environment, for the insurance company, it is urgent to change the model of claim service to attract more consumers and improve the competitiveness of the commercial health insurance in the market. Therefore, the direct payment model in the commercial health insurance should be of a certain value of research.
This paper first analyzes the problems existing in the current business health insurance compensation model, and puts forward the necessity of the commercial health insurance in the future to carry out the direct payment model, and then introduces the exploration and practice of the direct payment model of China's commercial health insurance, and analyzes the factors that restrict the direct payment model of China's commercial health insurance. This paper introduces the direct payment model of the state and China's social medical insurance, expounds the experience of their successful implementation of the direct payment claim model, and finally puts forward the author's suggestions on the construction of the direct payment model of China's commercial health insurance, and gives a brief introduction to the frame design of the direct payment claim system. As follows:
The first chapter mainly expounds the background of the topic, the significance of the research, the purpose of the study, and then summarizes the necessity of the direct compensation model for the development of China's commercial health insurance. In addition, it summarizes and summarizes the status of the research on the related problems of health insurance claims both at home and abroad, and finally expounds the main contributions and shortcomings of this paper.
The second chapter expounds the current status of the direct payment claim model of China's commercial health insurance. Many insurance companies have made a lot of attempts in direct compensation services, such as the Chinese life insurance company launched the "medical insurance Tong" claim system, Taikang Life Insurance Company launched the "health insurance" claims service, especially in the high-end medical insurance, direct payment of claim insurance The product continues to be hot. However, as far as the whole market is concerned, the direct payment claims service has not really become the mainstream. Based on this, the author from the market environment, the insurance demand side, the insurance supply side three angles, the reason that the direct payment is not widely popularized at present, the obstacles encountered in the analysis and exploration.
The third chapter introduces the mature direct compensation experience of medical insurance at home and abroad. First, in the market environment, the United States implements a medical insurance model based on commercial health insurance, which makes the insurance company have a larger market share, thus providing a good market environment for the implementation of the direct payment model. The German government has implemented a series of perfect bills and measures to create a good environment for commercial health insurance to achieve direct compensation. Second, in the business model, the German commercial health insurance company passed the health value chain and the American commercial health insurance passed the medical treatment. The operation mode of insurance cooperation and third party management makes it possible for the insurance companies to participate in the medical process of the medical institutions and form the interests community with the medical institutions, which is a good solution to the information asymmetry obstacles faced by the direct payment claims. Third, in the information system, the German medical indemnity settlement system has been set up in the study of the information system. The settlement platform and settlement system have been set up in the past seven years. China's social medical insurance has been carrying out the medical insurance information system gradually from the beginning of twenty-first Century with the help of the government. After years of construction, it has set up a large scale and laid a good foundation for the implementation of the direct payment model.
In the fourth chapter, according to the actual situation in China, in view of the restrictive factors of the second chapter, from the policy and system level, the management level and the system support level of the insurance company, some suggestions on the construction of the direct compensation model of commercial health insurance are put forward: (1) to improve the relevant laws and regulations; and to guide the professional classics (3) intervention in social medical insurance; (4) the introduction of third party management; (5) the development of combined medical care; (6) building a healthy industrial chain; and building up an interconnected platform;
The fifth chapter, since the commercial health insurance company has not established its own direct payment system, the author, based on the actual situation in China, proposes to use EDC (Electronical Data Capture, electronic data capture) technology to build a direct payment system, and analyzes the system needs, and constructs the basic framework of the system and the core flow. Cheng.
The main contributions of this paper are shown in three aspects. Firstly, the factors that restrict the development of China's direct compensation model for health insurance are analyzed from the three aspects of the insurance market environment, the insurance demand side and the insurance supply side. Second, according to the current actual situation in China, from the policy and system, the operation mode and the system support of three levels, Some suggestions are put forward on the construction of the direct payment compensation model for commercial health insurance. Third, around EDC technology, this paper puts forward the construction idea of the direct payment system for health insurance claims, mainly analyzes the claim qualification verification, claims verification and settlement settlement subsystem. The direct payment system constructed by the author is comparable to the other similar systems. Good enough to control the risk.
The shortcomings of this paper are shown in three aspects: first, because of the limited time and ability, the author does not analyze and elaborate the risk management and risk control of the direct payment model. Second, we can not make a scientific comparison and analysis of the cost and income needed to build the direct payment model. Third, this paper only advances the direct payment system of health insurance. The requirement analysis was performed, and the details of the system were not designed. In the design of the direct payment system, the insured has not taken into account the situation that the insured has been paid by other insurance companies.

【学位授予单位】：西南财经大学
【学位级别】：硕士
【学位授予年份】：2014
【分类号】：F842.684

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