Structure, process, effectiveness and efficiency of the check and review system in Japan's health insurance

Keeping medical costs at an adequate and affordable level cannot be realized by the efforts of medical facilities alone, nor by the revision of fee schedules and price schedules of drugs in Japan's health insurance systems. Rationalization and improvement in the efficiency of all of the systems, including the various insurance organizations and the organizations for review and payment, are imperative. This paper first examines the system of review and payment for insurance claims under Japan's health insurance systems with emphasis on three main points, namely (1) qualification checks, (2) check and review of insurance claims and (3) computerization of the screening process. Relevant issues facing the check and review system are then discussed.