Practice and Reflections on “Direct-billing Service” of Commercial Health Insurance in Hospitals: Experience of a Provincial-level Hospital in China

Abstract

The direct-billing collaboration between medical institutions and commercial health insurance institutions is an internationally applied method of commercial health insurance claims. This paper discusses the reasons why the direct-billing service of medical institutions is currently limited, including the trivial size of commercial health insurance and hospitals’ concern on cost control, by taking the practice of direct-billing service in a certain hospital in Wuhan as an example. It also summarizes the problems encountered in the operation, including the refusal to medical payment, the risks in excessive medical care, the increasing costs of medical institutions and acting against the equalization principle of medical service. The author then proposes several advices on the direct-billing service operated by hospitals, in terms of strengthening the risk control, taking part into the “Big Data” health management, reforming HIS system united with commercial insurance institutions and adjusting the pricing system of direct-billing service.