Project News

An online workshop took place on 12 October 2022 to share information and experiences of the claim management system, in particular, e-claim and claim review and audit, among participating 7 countries, namely Lao PDR, Viet Nam, Philippines, Indonesia, Sudan, Thailand, and Japan.

Effective claim management system, which realizes timely payments to healthcare providers as well as detection and prevention of inappropriate and/or fraudulent medical claims, is core of provider payment mechanism, and thus contributes to sound, viable, and efficient provision of quality health services.

Countries presented how they have been developing the claim management system and shared challenges in the process. A common challenge that they are facing was how they improve health information system to connect with claim management system. Especially, countries in transition from paper-based claim management system to electric system eagerly learned from other countries. Audit systems in some advanced countries like Thailand, Philippines and Indonesia were also of interest to participants.

A lecturer from Health Insurance Claims Review & Reimbursement Services, Japan showed a mature example of claim review system. The informative presentation included the comprehensive check method by combination of same month check and same institution-multiple months check, flow of electric claim review, re-review system as well as their organizational structure and the composition of the claim review committee that ensure efficient and fair operation.

The discussion highlighted that the countries need to continue developing claim management system in order to respond to new demands, such as reimbursement of home visit services and tele-medicine, which have increased in demand under COVID-19 pandemic. In addition, countries confirmed that the effective claim management system enables to provide quality service delivery.

We hope that the practical learning through the workshop will contribute to their way forward towards more effective and efficient claim management system in each country.