| 4. In which ways is the initiative creative and innovative?
Strategic Element 1: Conception and Legal Foundation for MFC Service
•Intense lobbying by civil society. Citizen groups regularly meet members of the National Assembly and senior officials at the MOHW, HIRA, and NHIS to raise concerns regarding excessive medical fees.
•Citizen groups raise public awareness through regional conferences, public hearings and the media.
•These efforts build momentum for legislative change. Citizen groups work with National Assembly to draft the legal foundation for the MFC system.
December 2002 – The National Assembly passes a law granting authority to HIRA and the NHIS to review medical fees on behalf of patients.
May 2004 – Administrative law is passed that healthcare facilities must comply with requests to provide information for MFC.
March 2009 – HIRA becomes sole government agency in charge of Medical Fee Checking System thereby reducing duplication.
Strategic Element 2: Design and Implementation of MFC System
•The MOHW, HIRA, and NHIS jointly convene a series of meetings with citizen groups to devise a system to protect citizens from excessive or inappropriate medical fees.
•Interagency MFC committee is formed to develop process and mechanisms for MFC system.
•MFC committee provides report on the step-by-step process, which is shared with stakeholders and given final approval by MOHW.
January 2004 – HIRA creates Medical Fee Checking department staffed by 16 members.
February 2004 – HIRA conducts first MFC informational and feedback sessions with healthcare facilities. These are subsequently held twice a year.
May 2004 – Medical Fee Checking System is launched nationwide
•Citizens can submit request to HIRA to verify that they were correctly charged for health services.
•Citizens can make request by sending a fax of the hospital bill or by in-person visits.
June 2005 – Medical Fee Checking System website is launched
Citizens can submit request online and receive a unique ID to track progress of case.
August 2006 – The MFC team is expanded with 21 members and a team leader. This team functions under auspices of customer service department.
April 2007 – “Happy Call” Center is established
•Citizens can call hotline to submit request and ask questions regarding hospital fees.
November 2008 – Pilot Project for Mobile Application is launched
•Pilot project with users assesses feasibility of smartphone enabled Medical Fee Checking requests.
February 2009 –Refund One-Stop Service (ROS) is launched
•HIRA acts as intermediary between patient and healthcare facility for reimbursements and timely refund.
March 2010 – Medical Fee Checking Process moves to paperless system.
* Petitions are made through website, smart device application, or in-person. In-person requests are filed electronically by HIRA staff.
Strategic Element 3: Continuous Citizen Engagement
A. Law, Policy, Action
•During MFC design phase, consumer groups successfully persuade government to make several changes in guidelines to expand coverage for certain health services.
•Once launched, quarterly reports from MFC service provide evidence of patterns of incorrect or fraudulent charges by hospitals to patients.
•Citizen groups demand action by government to: 1) clarify gray areas of covered vs. uncovered services and expand where appropriate, 2) induce health care facilities that have high frequency of incorrect charges to correct their behavior.
•National Assembly orders HIRA to conduct investigation in 2010 and audits in 2012 of major healthcare facilities.
B. System Enhancement
•HIRA holds regular meetings with consumer groups to solicit feedback on MFC system.
•Consumer groups are active stakeholders the design of the MFC system. They meet regularly with MFC committee to discuss the necessary features that will promote convenience, ease of use, and provide important information to citizens.
•Consumer group feedback led to improvements in website, establishment of Happy Call Center, and Medical Bill calculator.
| 5. Who implemented the initiative and what is the size of the population affected by this initiative?
The main stakeholders for the MFC initiative were as follows:
- The Health Insurance Review & Assessment Agency (HIRA) and the National Health Insurance Service (NHIS) convene stakeholder meetings and consultations. HIRA senior leadership and the HIRA Benefit Coverage Verification Department with their counterparts in NHIS lead the consultations, design and implementation of the Medical Fee Checking initiative. Prior to 2009, both HIRA and NHIS offered Medical Fee Checking Services to citizens. Subsequently, the National Assembly granted HIRA sole authority to implement the Medical Fee Checking initiative thereby reducing administrative duplication.
-The Ministry of Health and Family Welfare and the National Assembly Health Committee were involved in providing high-level oversight and recommendations during the initial stages of design and implementation.
Consumer Groups played a very important and active role in the conception, design, and implementation of the MFC system. The Consumer Research Advocacy Alliance, Consumer Advisory Group, and the Labor, Farmer, Consumer Group brought together representatives from numerous associations to provide their opinions and recommendations regarding MFC.
| 6. How was the strategy implemented and what resources were mobilized?
The Medical Fee Checking Service was integrated into HIRA’s core services since it was established in 2004. As a primarily customer-driven service, the majority of the costs are directed towards HIRA staff salaries. Initially there were 16 staff members dedicated to MFC who were placed within HIRA’s Customer Service Department, Benefit Coverage Division. Salary expenditures for these people were approximately $640,000 USD.
As of 2014, staff for the MFC service expanded to 55 people (including 3 IT and 2 “Happy Call Center” representatives) located at headquarters and HIRA branch offices. In 2013, the staff salaries totaled to approximately $3.3 million USD.
In general, expenditures for MFC service activities during the implementation phase have been related to direct client service or outreach. In 2014, approximately $163,000 USD were allocated as follows: $75,700 for the postal delivery of documents to citizens (47%), $30,000 for public relation efforts (18%), $15,300 for educational sessions (9%), $6,400 for hearings with medical institutions (4%), and $35,500 for other activities (22%). Thus, the majority of expenditures are directed towards document delivery. Even though the online method of the MFC service is popular, many citizens prefer to send and receive back paper copies of their medical bills and MFC-related documents to have physical proof of their request.
The annual expenditures for MFC have been generally stable during the implementation phase. Notably, however, major increases or decreases in expenditures have been associated MFC enhancements. For example, the activities expenditures in 2010 was $234,000 USD but declined to $169,000 the following year from cost savings with the introduction of the online option for the MFC service. In 2013, the budget increased for additional promotional and advertisement campaigns for the MFC service.
| 7. Who were the stakeholders involved in the design of the initiative and in its implementation?
1.Multiple convenient means of submitting and tracking medical fee verification requests.
Citizens can submit medical fee verification requests by contacting the Happy call center, submitting online, or through smartphone. The most popular method is online, followed by smartphone, and Happy Call. Moreover, with a unique ID, citizens can track at what stage their case is being processed. The MFC system has taken advantage of advances in technology to focus on improving the convenience of citizens and lift the administrative, financial, and time burden in dealing with the healthcare system.
2.Refund One-Stop Service.
As of 2009, HIRA ensures full and timely reimbursement to patients. Patients no longer have to contact hospitals over bill disputes and suffer delays in receiving a refund. Moreover, patients – as ongoing consumers - can maintain good relations with healthcare providers. Instead, HIRA asks healthcare providers to choose the refund method between direct refund to applicants or payment of refund is deducted from their next insurance reimbursement from the NHIS.
3.Streamlined system with speedy processing of high-volume of claims
The MFC system has improved each year to better serve citizens. In particular, the speed of processing claims has declined significantly over time. In 2010, it took an average of 90 days, in 2012 - 78 days, in 2013 -58 days, and in 2014 the average is projected to be 48 days – nearly half the amount of time since 2010. The MFC system has processed a significant volume of claims between 15,000-44,000 annually from 2007-2013.
4.Data collection system to systematically track evidence of errors/fraud
HIRA collects and aggregates data annually from all requests to assess patterns and identify problems (e.g. one hospital with many cases of overcharging patients). This data serves as the basis to conduct visits/audits by HIRA staff to health facilities. Moreover, it leads to clarification by HIRA in its guidelines.
5.Review of the Emergency Medical Fund – Every province and district office has an Emergency Medical Fund, which pays the out-of-pocket expenses of low-income citizens. Since the Emergency Medical Fund is government aid for low-income citizens, these funds are vulnerable to fraudulent charges by healthcare providers. Since 2013, HIRA has reviewed any claims over $1500 from Emergency Medical Funds throughout the country. In one year, 1150 cases from these funds were submitted of which 66% received refunds. The amount saved through MFC review of Emergency Medical Funds totaled to approximately $100,000 USD.
| 8. What were the most successful outputs and why was the initiative effective?
An interagency MFC committee, which led the design and implementation of the MFC system, was responsible for reporting the progress of MFC implementation to key stakeholders:
High-level political oversight was provided by members of the National Assembly and the Ministry of Health and Welfare. During implementation, the MFC committee formally reported to the MOHW on a monthly basis and was in regular contact with senior officials.
-The MFC committee outlined the objectives and process for the MFC service, which was reviewed and approved by the MOHW and subsequently shared with stakeholders.
-The MFC committee reported the anticipated budget, timeline, and principal activities for the first (in person visits, fax) and subsequent version of the MFC service (on-line, smartphone)
-Examples of reported activities and indicators include: # of customer service staff hired for MFC, # and description of consultations and outreach activities with healthcare providers, progress on development of database to store and track verification requests,
Given the leading role of citizen groups in spurring the creation of MFC system, the committee also reported to and solicited feedback from consumer groups on a monthly basis. Consumer groups monitored several critical enhancements in service, which they suggested (e.g. Happy Call Center) to improve public service delivery.
Within HIRA, senior leadership from each department as well as the HIRA president received regular reports on the rollout of MFC service.
Once the service was launched, each of these groups continued to receive regular (monthly and annually) reports on key indicators related to the output of the MFC service. These include:
# of verification requests submitted, # granted refund, # denied refund, # withdrawn cases, amount of money refunded. These statistics form the basis of regular evaluations of the behavior of individual and aggregate healthcare facilities to identify where there are continued problems or improvements. This data also identifies patterns in problems (e.g. one service being frequently checked for verification). These regular evaluations of MFR made by these groups have led to recommendations for visits, audits, and clarifications in guidelines.
| 9. What were the main obstacles encountered and how were they overcome?
The main challenge during the implementation of the Medical Fee Checking System came from the medical establishment who expressed very vocal concern that the very premise of the system would cause the public to not trust the healthcare system. They argued that the creation of a medical fee checking system would give the impression that fraud and exploitation of vulnerable patients – particularly the elderly and infirm – were rampant in Korea.
HIRA recognized these concerns as valid and had many consultations with the medical community to address them. They focused on clarifying guidelines between “covered” and “uncovered” services and that visits by HIRA staff were not of a punitive nature, but opportunities to address problems and change procedures to prevent future errors in medical fee charges to patients.
However, it must be recognized that despite the objection by the medical community to the Medical Fee Checking system, the call for such a system was very strong from consumer groups, citizens, and members of the National Assembly.