本文選題：健康保險 + 直付理賠��； 參考：《西南財經(jīng)大學(xué)》2014年碩士論文

【摘要】：自上世紀(jì)90年代初中國保險業(yè)恢復(fù)以來,中國商業(yè)健康險業(yè)務(wù)發(fā)展迅猛,占據(jù)了人身保險10%以上的市場份額。商業(yè)健康險全年保費(fèi)收入從1999年的36.5億元增加到了2013年的1123.5億元。尤其是2005年以后,人保健康、平安健康、昆侖健康、和諧健康等四家專門性健康保險公司的陸續(xù)成立,標(biāo)志著中國商業(yè)健康險的發(fā)展進(jìn)入了新的階段。 但是,從保險行業(yè)整體發(fā)展水平上看,商業(yè)健康保險的發(fā)展速度遠(yuǎn)低于人身保險整體增長速度。商業(yè)健康保險在發(fā)展過程中遇到了不少的阻礙,其中,落后的理賠模式是其發(fā)展的主要制約因素之一。在國際上,很多發(fā)達(dá)國家的健康保險都推行的是“直付式理賠(direct-billing)"服務(wù)模式。被保險人在醫(yī)院就醫(yī)過程中,不需要先向醫(yī)院支付現(xiàn)金,再去保險公司理賠,醫(yī)療服務(wù)費(fèi)用直接由保險公司對醫(yī)院進(jìn)行結(jié)算。在國內(nèi),隨著近幾年各地區(qū)完善了自身的醫(yī)療保險信息管理系統(tǒng),基本醫(yī)療保險的參保人至少可以在本地區(qū)享受就醫(yī)直付理賠服務(wù),但是中國商業(yè)健康保險目前仍停留在“買單式理賠”的階段。參加商業(yè)健康保險的被保險人,在指定的醫(yī)療服務(wù)機(jī)構(gòu)就醫(yī)后,需要先全額付款,然后帶著付款憑證以及費(fèi)用清單到保險公司索賠。這種事后的理賠模式,無法滿足被保險人對醫(yī)療費(fèi)用直接結(jié)算的需求,不能解決被保險人的燃眉之急。一方面,由于商業(yè)健康保險的參保人并沒有享受到更優(yōu)質(zhì)的理賠服務(wù),因而,在一定程度上影響了健康保險的市場需求。另一方面,買單理賠模式需要被保險人自己收集相關(guān)理賠材料,然后向保險公司索賠容易讓被保險人產(chǎn)生反感情緒,造成不必要的理賠糾紛,從而損害被保險人和保險公司的利益因此,在目前基本醫(yī)療保險努力實現(xiàn)廣覆蓋的大環(huán)境下,對于保險公司來說,要想在夾縫之中求生存求發(fā)展,亟需轉(zhuǎn)變理賠服務(wù)模式,以吸引更多的消費(fèi)者,提高商業(yè)健康保險在市場上的競爭力。因此,直付理賠模式在商業(yè)健康險中的應(yīng)用具有一定的研究價值。 本文首先分析目前商業(yè)健康保險理賠模式存在問題,提出商業(yè)健康保險未來推行直付理賠模式的必要性；接下來介紹中國商業(yè)健康保險直付理賠模式的探索實踐,分析目前制約中國商業(yè)健康保險直付理賠模式的因素；然后,對發(fā)達(dá)國家及中國社會醫(yī)療保險的直付理賠模式進(jìn)行介紹、闡述,總結(jié)他們成功推行直付理賠模式的經(jīng)驗；最后,提出筆者對構(gòu)建中國商業(yè)健康保險直付理賠模式的建議,并對直付理賠系統(tǒng)的框架設(shè)計進(jìn)行了簡要的介紹。具體內(nèi)容和主要觀點(diǎn)如下所述： 第一章主要闡述了論文的選題背景、研究意義、研究目的,進(jìn)而總結(jié)出中國商業(yè)健康保險發(fā)展直付理賠模式的必要性。另外,對國內(nèi)外對健康險理賠相關(guān)問題的研究現(xiàn)狀進(jìn)行了總結(jié)與歸納,最后闡述了本論文的主要貢獻(xiàn)與不足。 第二章對中國商業(yè)健康險直付理賠模式的現(xiàn)狀進(jìn)行了闡述。許多保險公司在直付理賠服務(wù)方面做出了不少嘗試,如中國人壽推出了“醫(yī)保通”理賠系統(tǒng)、泰康人壽推出“健保通”理賠服務(wù)等,特別是在高端醫(yī)療保險方面,直付理賠保險產(chǎn)品持續(xù)火熱。但是,就整個市場來看,直付理賠服務(wù)并未真正的成為主流。基于此,筆者從市場環(huán)境、保險需求方、保險供給方三個角度,對直付式理賠目前未能全面推廣的原因,所遭遇到的障礙進(jìn)行了分析探究。 第三章介紹了國內(nèi)外醫(yī)療保險成熟的直付理賠經(jīng)驗。第一,在市場環(huán)境方面,美國施行的是以商業(yè)健康保險為主的醫(yī)療保險模式,使得保險公司擁有較大市場份額,從而為直付理賠模式的推行提供了良好的市場環(huán)境。德國實行的是社會醫(yī)療保險為主,商業(yè)健康保險為輔的醫(yī)療模式。德國政府實施了一系列完善的法案、措施,為商業(yè)健康險能夠?qū)崿F(xiàn)直付理賠創(chuàng)造了良好的環(huán)境。第二,在經(jīng)營模式方面,德國商業(yè)健康保險公司通過打造健康價值鏈,美國商業(yè)健康保險通過醫(yī)保合作、第三方管理機(jī)構(gòu)等經(jīng)營模式,使得保險公司能夠參與到醫(yī)療機(jī)構(gòu)的醫(yī)療過程中,與醫(yī)療機(jī)構(gòu)形成利益共同體,很好的解決了直付理賠所面臨的信息不對稱的障礙。第三,在信息系統(tǒng)方面,德國成立了“醫(yī)療賠付結(jié)算系統(tǒng)”研究中心,歷時七年時間,建立了結(jié)算平臺與結(jié)算系統(tǒng)。中國社會醫(yī)療保險借助與政府的大力推行,自21世紀(jì)初開始逐漸推行醫(yī)療保險信息系統(tǒng),經(jīng)過多年的建設(shè),己初具規(guī)模,為直付理賠模式的推行奠定了良好的系統(tǒng)基礎(chǔ)。 第四章,結(jié)合中國目前的實際情況,針對第二章提出的直付理賠模式的制約因素,從政策與制度層面、保險公司經(jīng)營層面及系統(tǒng)支撐層面,提出自己對商業(yè)健康保險直付理賠模式構(gòu)建的幾點(diǎn)建議：①完善相關(guān)法律法規(guī)；②引導(dǎo)專業(yè)化經(jīng)營；③介入社會醫(yī)療保險；④引入第三方管理；⑤發(fā)展結(jié)合式醫(yī)療；⑥打造健康產(chǎn)業(yè)鏈；⑦搭建互聯(lián)平臺；⑧構(gòu)建直付理賠系統(tǒng)。 第五章,由于目前商業(yè)健康險公司尚未建立自己的直付理賠系統(tǒng),因此,筆者根據(jù)中國目前的實際情況,提出利用EDC(Electronical Data Capture,電子數(shù)據(jù)捕獲)技術(shù)來構(gòu)建直付理賠系統(tǒng),并對系統(tǒng)需求進(jìn)行了分析,構(gòu)架出系統(tǒng)基本框架和核心流程。 本文的主要貢獻(xiàn)主要表現(xiàn)在三個方面：第一,從保險市場環(huán)境、保險需求方以及保險供給方三個角度對制約中國健康險直付理賠模式發(fā)展的因素進(jìn)行了分析。第二,根據(jù)中國目前的實際狀況,從政策與制度、經(jīng)營模式、系統(tǒng)支持三個層面,對商業(yè)健康險直付理賠模式的構(gòu)建提出了自己的幾點(diǎn)建議。第三,圍繞EDC技術(shù),提出健康險理賠直付系統(tǒng)的構(gòu)建思路,主要對理賠資格驗證、理賠審核和理賠結(jié)算子系統(tǒng)進(jìn)行了分析。筆者所構(gòu)建的直付理賠系統(tǒng),相比于其他同類的系統(tǒng),能夠更好的把控風(fēng)險。 本文的不足表現(xiàn)在三個方面：第一,由于時間和能力有限,筆者沒有詳細(xì)的分析與闡述直付理賠模式的風(fēng)險管理與風(fēng)險控制。第二,未能對構(gòu)建直付理賠模式所需成本和收益進(jìn)行科學(xué)的比較分析。第三,本文只對健康險直付理賠系統(tǒng)進(jìn)行了需求分析,而未能把系統(tǒng)細(xì)節(jié)給設(shè)計出來,且在直付理賠系統(tǒng)設(shè)計中未能考慮被保險人己經(jīng)在其他保險公司處獲得賠付的情況。
[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.

【學(xué)位授予單位】：西南財經(jīng)大學(xué)
【學(xué)位級別】：碩士
【學(xué)位授予年份】：2014
【分類號】：F842.684

【參考文獻(xiàn)】

相關(guān)期刊論文 前3條

1 楊玲;;我國健康保險發(fā)展中存在的問題及對策[J];華章;2011年36期

2 王川;陳濤;;德國醫(yī)療保險制度的改革及啟示[J];經(jīng)濟(jì)縱橫;2009年07期

3 鄭建中;;健康險的外熱內(nèi)冷與無限商機(jī)[J];中國保險;2007年05期

，

本文編號：1856269