The Change in the Behavior of Supplementary Insurers and Insured Individuals Before and After the Implementation of the Health System Reform in Hospitals Affiliated to Mashhad University of Medical Sciences

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BADIEE AVAL SHAPOUR; ADEL AMIN; EBRAHIMIPOUR HOSEIN; Javan Biparva Akbar; Askarzadeh Elaheh

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Journal: HEALTH INSURANCE Year:2019 | Volume:1 | Issue:4 Page(s): 160-164

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Title

The Change in the Behavior of Supplementary Insurers and Insured Individuals Before and After the Implementation of the Health System Reform in Hospitals Affiliated to Mashhad University of Medical Sciences

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Keywords

Health Care Reform

Supplementary Insurance

Health Planning Support

Abstract

Introduction: A significant amount of treatment cost is paid by health insurance organization. Insurance companies mostly use reliable people to audit documents, but due to the very high number of documents and the limitation of time and human resource, it is almost impossible to consider documents carefully and more importantly, some infringements are not identifiable according to only one document, but identifiable by accumulation of documents and intelligent analysis based on data mining. Detection of beneficial referral (self-referral and kickback) that a doctor refers a patient to a specific pharmacy that has benefits for him, is one of these things. Methods: In the current study, data pool was prepared using Tehran Health Insurance data until 2017 and then after eliminating faulty data, according to network mining methods, actions were taken to detect anomalistic referrals on the network, data filtering, and weighing the edges of the network based on the views of reliable people. This method was implemented in the Knime environment and a short list was presented to monitoring department of the health insurance organization. Results: In the current study, according to the importance of detected interactions during network mining process between doctors and pharmacies, and using visual tools in Knime, it was observed that 73 doctors had significant relationships with 26 pharmacies. Conclusions: Inspectors of health insurance organization can have a more accurate and more effective examination by spending less time and human resource according to examination patterns based on network mining and visualization.

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APA: Copy

BADIEE AVAL, SHAPOUR, ADEL, AMIN, EBRAHIMIPOUR, HOSEIN, Javan Biparva, Akbar, & Askarzadeh, Elaheh. (2019). The Change in the Behavior of Supplementary Insurers and Insured Individuals Before and After the Implementation of the Health System Reform in Hospitals Affiliated to Mashhad University of Medical Sciences. HEALTH INSURANCE, 1(4 ), 160-164. SID. https://sid.ir/paper/265941/en

Vancouver: Copy

BADIEE AVAL SHAPOUR, ADEL AMIN, EBRAHIMIPOUR HOSEIN, Javan Biparva Akbar, Askarzadeh Elaheh. The Change in the Behavior of Supplementary Insurers and Insured Individuals Before and After the Implementation of the Health System Reform in Hospitals Affiliated to Mashhad University of Medical Sciences. HEALTH INSURANCE[Internet]. 2019;1(4 ):160-164. Available from: https://sid.ir/paper/265941/en

IEEE: Copy

SHAPOUR BADIEE AVAL, AMIN ADEL, HOSEIN EBRAHIMIPOUR, Akbar Javan Biparva, and Elaheh Askarzadeh, “The Change in the Behavior of Supplementary Insurers and Insured Individuals Before and After the Implementation of the Health System Reform in Hospitals Affiliated to Mashhad University of Medical Sciences,” HEALTH INSURANCE, vol. 1, no. 4 , pp. 160–164, 2019, [Online]. Available: https://sid.ir/paper/265941/en

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