[Insured-Specific Outpatient Claims Data in Private Health Insurance - Part 2: Data Origin and Data Flow]

Area of Science:

• Health Services Research
• Health Informatics
• Data Science

Background:

• Scientific research using claims data from private health insurance (PHI) companies requires understanding regulatory processes, data submission, billing, and storage.
• Previous studies indicate that PHI claims data can be utilized similarly to statutory health insurer data when its specific features are understood.

Purpose of the Study:

• To provide a fundamental understanding of the creation and flow of insured person and billing data within the private health insurance system for outpatient medical care, including medication.
• To illustrate processes and unique features of the private health insurance system using an exemplary data flow model.
• To assist decision-makers and data analysts in planning studies and preparing/evaluating PHI claims data by highlighting administrative and content-related challenges.

Main Methods:

• Systematic illustration of processes and special features in the private health insurance system using an exemplary data flow model for outpatient care and medication.
• Analysis of data generation particularities and their content-related consequences.

Main Results:

• The study provides a detailed overview of the data flow for insured persons and associated billing within the private health insurance sector for outpatient services.
• It highlights the importance of understanding specific processes and data characteristics unique to private health insurance claims data.
• Data availability and quality assessments must be conducted individually for each PHI company due to varying IT infrastructures and insurance rates.

Conclusions:

• A thorough understanding of the data flow and associated challenges is essential for data analysts working with private health insurance claims data.
• Future research should focus on linkage methods and integrating primary/survey data for validation studies to enhance the empirical knowledge base.
• Digitalization trends, such as electronic invoicing and prescriptions, hold the potential to improve the content and availability of health-related claims data.