Department of Planning, National Health Insurance Administration, Taipei, Taiwan.
Department of Medical Affairs, National Health Insurance Administration, Taipei, Taiwan.
Sci Rep. 2022 Jul 16;12(1):12195. doi: 10.1038/s41598-022-16536-1.
The effects of anonymity on utilization review has never been examined in the real world. This study aimed to evaluate the impact of removing anonymity protection for claims reviewers on their review decisions. Using a single-blinded repeated measures design, we randomly selected 1457 claims cases (with 12,237 orders) that had been anonymously reviewed and reimbursed in 2016 and had them re-reviewed in a signed review program in 2017 under the Taiwanese National Health Insurance scheme. The signed review policy significantly decreased the likelihood of a deduction decision at the case and the order level (P < 0.001). Furthermore, signed reviewers tended to make more "too lenient" decisions, and were less likely to make "too harsh" decisions. Removing anonymity protection dramatically reduced the deduction rate and overturned the tendency of decisions from "too harsh" to "too lenient". However, whether to maintain the anonymity of utilization reviews is a challenge for health authorities around the globe.
在现实世界中，从未有人研究过匿名对利用审查的影响。本研究旨在评估取消理赔审查员匿名保护对其审查决策的影响。我们采用单盲重复测量设计，随机选择了 2016 年匿名审查并报销的 1457 份理赔案例（共 12237 份医嘱），并在 2017 年根据台湾全民健康保险计划，在签署审查计划下重新审查。签署审查政策显著降低了案例和医嘱层面的扣款决策可能性（P<0.001）。此外，签署审查员倾向于做出更多的“过于宽松”的决策，而不太可能做出“过于严格”的决策。取消匿名保护极大地降低了扣款率，并扭转了从“过于严格”到“过于宽松”的决策趋势。然而，是否保留利用审查的匿名性是全球卫生当局面临的一个挑战。
