全民健康保險已於民國八十四年三月一日實施，依據過去勞工保險醫療給付所須 審查之資料量來推估，全民健保之資料量門診每年至少有九億三仟多萬項，而住院每年亦有 二千六百多萬項。面對如此龐大之資料量，將來審查工作勢必要透過資訊電腦化，建立審查 標準，利用媒體申報由電腦自動核對，符合標準者即予核付，超出標準異常案例，再以人工 審核，利用差異分析及異常管理之理念、工作簡化之制度設計，達到低成本高效率、確保醫 療品質、 簡化行政手續及提高給付時效等目標。 全民健康保險住院支付制度未來將採用 DRGs，在國內版 DRGs 尚未建立前， 為長遠之計，而有初期採用論量計酬 (FFS) 及論病例 計酬 (Case Payment) 之混合制，再過渡至國內版 DRGs。 DRGS 之推動最被垢病的就是醫 療品質無法確保，因此建立一套公平、公正、及公開之合理審查制度，以確保醫療品質，同 時簡化行政手續、迅速合理支付醫療費用及節省行政成本，實為當務之急。本研究針對住院 部份即將實施論病例計酬，為確保醫療品質及不影響病人醫療的個別性下, 由長庚紀念醫院 各相關專科擬訂並經各專科醫學會審查，已完成一般外科等十專科之腹股溝疝氣等廿八項疾 病中英文對照之『基本治療程序要求』， 以建立一套 PPS 制度下之醫療審查標準模式，可 據以參考推廣至未來全部 DRGs 標準。茲建議全民健保優先由這廿八種疾病試辦並繼續由其 他醫學中心及各專科醫學會合作，擴大論病例計酬之實施範圍。但在訂定論病例計酬標準時 ，必須考慮各不同等級醫院之平均疾病嚴重度差異，以建立公平合理之醫療給付制度。最後 本研究針對相關審核模式及電腦流程提出建議。

　　　　　National Health Insurance (NHI) will be implemented on March 1, 1995. The estimate annual number of claim items reviewed under NHI will amount to at least 930 million for outpatient and 26 million for inpatient respectively. The only way to process those data efffiently is to set up standards for reivew, and to identify abnormal cases for manual review throughout the computer analysis. finally, the objectives of NHI claim review system are quality assurance, process simplification, shortened reimbursement time by the design of simplification & the management of outliners. With respect to the case payment which will be adopted in inpatient reimbursement, 28 minimum requirements which are written in English & Chinese, based on diagnosis, have been completed. These minimum requirements were spelled out by the related departments of Chang Gung Memorial Hospital and reviewed by different associations of specialties in an effort to establish a peer review model under PPS or under DRGs in the future. These 28 cases are highly recommended to be implemented under Case Payment, and more minimum requirements should be completed by the cooperation of medical centers and specialty associations. In addition, the average variation of severity of illness in different levels of hospitals must be taken into consideration when setting up the reimbursement for case payment in order to pursue a fair & reasonable payment system. Finally, the related models of peer review and computerization process are also presented here.