Applying lot-by-lot double sampling plan to reform Taiwan National Health Insurance auditing system

摘要

This paper seeks to design an elaborate and effective “sampling audit and payment process” for a single-payer system of national health insurance. Furthermore, contrive incentive mechanisms in the “sampling audit and payment process” to make the healthcare providers willing to apply for their medical claim payments straightforwardly. A framework of “medical claim payment auditing by double sampling plan (MCPAD)” procedure based on the lot-by-lot double sampling plan was proposed to curb the growth of medical expenses. The proposed procedure entertains several advantages, including: (1) it meets international standards of sampling plan; (2) it simplifies the auditing process; (3) it reduces sample size and auditing costs; and (4) it encourages healthcare providers using an honest medical claim payment through the incentive mechanisms. This study successfully reduces the sampling cost and effectively audits the claimed medical fees as well as encourages healthcare providers to straightforwardly apply for their medical claim payments. Practically, the proposed MCPAD procedure is also applied to healthcare provider. It is anticipated that the proposed procedure in other nations in the future.