With a market size of 34 billion SAR, market experts consider the Saudi private healthcare sector to be one of the largest in the area. Health insurance companies are responsible for 53% of the total annual revenue in this sector and Saudi Arabia's national transformative strategy plans to gradually grow the market size by more than 141 billion SAR through privatization by 2030.
However, unlike in other global marketplaces, the relationship between providers and payers is not as transparent or standardized. Experts attribute these problems mostly to a lack of sound legal and financial frameworks. Such restrictions have a negative impact on the market's growth rate as well as the fairness of market dynamics among stakeholders. In addition, the average claim rejection rate for small to medium size healthcare providers is believed to be between 20% and 25%.
Glance Care's team brings to light some of the market's dynamics, regulators' rules, challenges, and available solutions in a detailed whitepaper after conducting a 6-month intensive market study. Solutions to the problems highlighted above are also detailed along with easily integratable tools that can help healthcare providers and institutions improve their annual claim revenue turnover and reduce claim rejection rates.
In Saudi Arabia, the average healthcare claims rejection rate is around 20% - 25% for small and medium-sized hospitals. This translates to delays and loss of revenue amounting to 3.5 – 4.5 billion SAR every year. This figure is poised to increase further as the healthcare market gears up to increase its market size to 141 billion SAR by 2030.
Getting around the issue of claims rejections requires specialized knowledge of what causes these rejections in the first place. Here are 9 reasons that contribute to the rejection rate for healthcare claims in Saudi Arabia.
Medical necessity adjudication is a complex process, especially in the local market. It is primarily due to the lack of standardized medical documentation and clinical practice guidelines. Ideally, medical claims should serve a well-defined diagnosis/problem as a clear justification. However, most of the local medical practitioners have been trained to rely on exploratory testing to formulate an understanding that has shown to be cost-ineffective—as a result, submitting a claim with an inaccurate or inappropriate diagnosis mostly leads to a denial for excessive or unnecessary service. Using GlanceClaim™ Checker, 40.5% of the analyzed claims lack appropriate justification.
One of the uniquely disruptive factors that affect the medical claim quality is the patient (policyholder) influence on the decision-making. For instance, patients may influence the medical practitioner to gain certain services without a justified medical reason.
In January 2020, the Saudi health council mandated the Australian coding standard for inpatient encounters. However, it has been challenging to implement this change due to insufficient medical coding personnel. We found that 27.8% of the analyzed claims suffered from coding errors.
Medical claim filing in Saudi Arabia follows specific standards and requirements appointed by the local regulator, i.e., the Saudi Council of Health Insurance (CHI), to ensure adequate and fair claims processing/reimbursement. Standards include utilizing the unified claim and approval form (UCAF / DCAF 2.0) and the claim’s minimum data set (MDS v3.1). Failure to comply with these requirements jeopardizes the claim’s integrity and fair reimbursement. We found that most of the healthcare providers are not fully compliant. Financial limitations, operational restrictions, and technical immaturity played a major role.
Accurate transmission of data between stakeholders is one of the most significant challenges in the Saudi market. The reason for this appears to be a lack of standardized data transmission protocols. However, the new regulatory changes adopting the National Platform for Health and Insurance Exchange Services (NPHIES) standards, which are a local modification of HL7-FHIR standards, will significantly improve the market's technical infrastructure, allowing for greater interoperability and better data exchange. Reflecting on the sampled EHR systems, 2 out of 3 are non-compliant with the minimum data set (MDS v3.1) requirements due to limitations in the system’s data architectural design.
Contractual terms and policies govern the reimbursement process, which includes pricing, communication standards, pre-approval policies, financial considerations, etc. However, translating these terms into effective processes is operationally challenging, expensive, and potentially restrictive to the workflow. We found that 2.9% of the studied claims lacked adherence to medical policies.
Payers consider expired subscriptions, invalid relationships, or inaccurate plan details invalid membership. This issue was more prevalent among busy HCPs with poor internal processes. However, NPHIES ensure current and accurate data transmission for instant validation.
The policyholder may consume more benefits than the policy allows, which creates a reason for denial. Due to the lack of transparency in information exchange between stakeholders, policyholders may abuse loopholes. Consequently, we found that HCPs rely heavily on requesting pre-authorization to mitigate the risk of claims rejection.
When adjudicating claims, some of the major insurance companies in the Saudi market consider patient safety as a denial measure. For example, prescribing an intravenous antibiotic without proper indicative documentation or co-administering multiple drugs without checking for interaction are the bases for many reimbursement denials. Without appropriate clinical decision support systems, patient safety should remain a valid reason for claims denials in the market.
With the overwhelming daily operations, submitting claims on time is one of the HCP’s most stressful tasks. Without supportive workflow, infrastructure, and policies, HCPs continue to trade between claim quality versus timely monthly filing.
GlanceClaim™ is designed to improve the quality of medical claims by detecting and resolving medical and technical vulnerabilities. This solution has been developed keeping the Saudi healthcare sector in mind and helps 3 key stakeholders of the healthcare-insurance claim cycle – the medical team, the RCM team, and executive management. GlanceClaim™ also reduces coding discrepancies by up to 87%. Read the whitepaper or learn more about GlanceClaim™ here.
The COVID-19 Pandemic has not only wrecked havoc upon the healthcare sector and has endangered the lives of millions, but has also almost equally affected businesses and economies. It has also affected each individual person differently. Everyone seems to be affected and stuck under the additional burdens and loads posed by the COVID-19 crisis, and it is almost evident that coming out of this crisis and burden would no doubt be a hard and time-consuming task.
If we talk in particular about the people who are directly affected by it - that is, the healthcare personnel and the junior doctors and students, then they have undoubtedly had their fair share of loss and have faced a lot of troubles with regards to their studies and practice and clinical rotations.
As this is a well-established fact that a doctor is useless without any practical implementation of his skills, then this very fact could prove to be very disappointing and discouraging for all the aspiring medical students and junior doctors because they can no longer be exposed like before to the patients and try out their skills.
With the advent of COVID-19, the entire educational sector was forced to move to virtual platforms. This seemed favorable at that time as keeping the health of both the tutor/facilitator and the student was the main priority.
For medical students, this was not that favorable. More than half of their studies is based on real-life patients and real-time clinical scenarios.
This sudden shift from live, hospital exposure to a screen-bound platform was not only limiting, but also caused an immediate rift to be created in their studies and clinical exposure.
When a group of Final Year Medical students from the UK was asked to give their opinions on how COVID-19 affected their studies and most importantly their clinical observerships, the majority of the students expressed their disappointment and reacted that they were reluctant to continue the upcoming academic year as they had to safeguard both - their lives as well as their future careers at a time as crucial as this.
Medical students and junior doctors who are yet to start their training years feel confused about their next step - there has been a definite and visible education gap which has done no good but only created problems for everyone out there. There still exists an uncertainty about how long this pandemic will last and for how long it will continue to keep us restricted within our homes.
But one thing is evident - the students of today and the doctors of tomorrow would be more well-versed than us on how to deal with large-scale problems and disease outbreaks like the one that they are experiencing at a time like this.