健保署在全國醫療資源處於「資源有限、需求無限」情況下，除了推動各種多元化支付制度實施外，於各醫院申報費用後，依「全民健康保險醫事服務機構醫療服務審查辦法」，每季採用抽樣方式進行「專業審查」流程，依法逕予核減醫療費用，醫院端如何儘早提出申復以爭取最多的補付金額，是目前醫務行政面臨的首要問題。本研究利用系統模擬依照現況申復之作業流程，以專責承辦人科別重新配置為主，並透過系統模擬之最適化，提升醫院能儘早申復之實效性，本研究發現現況申復之作業流程總時數需要28.6小時，透過本研究總時數可縮短為12小時或6.9小時，達成縮減58%~75%作業流程總時數，本研究依專責承辦人科別重新配置，不僅達成醫院端儘早提出申復，更可提供其他醫院管理者做為參考。 “Limited health care resources but unlimited demands" is a challenge the National Health Department constantly faces。In addition to promote the diversification of the various payment systems, the Department invites medical professionals to reviews fee applications according to the "National health insurance medical service fees review regulations" on a quarterly basis, and questionable fee applications will be waived until further clarification (appeal) is provided by the applying hospital.How to complete the appeal process as soon as possible in order to get the most possible pay is an issue of tremendous importance for medical administrators.In this study, a system simulating reassignment of medical divisions covered by responsible staff involved in the appeal process for waived health insurance fee was used to investigate the time required for the process。After making adaptions based on the simulation results,it was revealed that the the time requirement of the appeal process is significantly reduced from 28.6 hours in the present system to 6.9 -12 hours, or 6.9 hours(a reduction of 58% to 75%) This new method can facilitate the hospital to complete the appeal process as soon as possible and receive the most possible pay.
