Tamsulosin and Donepezil insurance cuts were most objected

HIRA introduces cases of 1st review adjustments and method of filing objections

It was found that most amount of objections were filed for examination fees and outpatient prescription drugs after the Health and Insurance Review Service's adjustments such as cutbacks on items that do not meet the review criteria for insurance benefits.

 

HIRA had recently held a ‘2021 Briefing session on filing objections’ for medical care institutions.

 

In the session, HIRA introduced cases of 1st adjustments after review that received the most amount of objections.

 

By each treatment category, objections filed for examination fees accounted for 23%, followed by outpatient prescription drugs 20%, emergency aid and operation fees 17%, and injection fees 12%.

 

Among outpatient prescription drugs, adjustment on the oral tablets ‘Tamsulosin’ and ‘Donepezil,’ and the denosumab injection received the most objections.

 

Results of objections filed for adjustment made showed that Tamsulosin was being applied insurance benefit for its indication, ‘dysuria from benign prostatic hypertrophy,’ and for the off-label use in neurogenic bladder.

 

However, in many cases, adjustments were made for unconfirmed benign prostatic hypertrophy or bladder disease diagnosis.

 

When the medical institution files an objection regarding the adjustment, the institution needs to attach a medical record that shows proof of diagnosis related to benign prostatic hypertrophy.

 

Cases of adjustments made to the denosumab injection showed that cuts were made due to unconfirmed osteoporosis disease, unconfirmed BMD test results, and an excessive number of follow-up tests results, among others.

 

Applicable medical institutions need to confirm the eligible subjects and period of administration as specified in the notification, and when filing an objection, medical records that can confirm osteoporosis, period and frequency of administration, etc.

 

or radiation reading sheets, bone density test results that can confirm osteoporotic fractures need to be attached to the objection.

 

Most adjustments were made for Donepezil oral tablets due to unconfirmed Alzheimer-type dementia diagnosis, unconfirmed test results including CDR, MMSE, and errors in description format.

 

To avoid insurance cuts, medical institutions need to check the subject eligible for administration, evaluation method and enter the dementia test results under the specific classification code ZT007 as specified in the instructions on how to write up the claim for benefits.

 

In filling out the Donepezil claim form, the test results should be listed in the order of MMSE, CDR, and GDS, then the test dates should be listed.

 

When filing an objection, the diagnosis and test results that can confirm Alzheimer’s must be attached.

 

Meanwhile, HIRA has been operating inspection services including the pre-inspection service that allows for inspection, modification, and remedies before submitting the claim and a claims error service that allows for corrections and supplements to be made within 2 days after filing the claim.

 

Medical institutions may check for errors identified before claiming benefits through the pre-inspection service to prevent adjustment of medical expenses, minimize supplementary claims, and prevent filing objections.