Structured interviews and qualitative/quantitative claims data analysis.
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 service 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 of excessive or unnecessary service. Using GlanceClaim Checker, 40.5% of the studied health claims lack appropriate justification.
One of the uniquely disruptive factors that affect the medical claim quality is the patient/policyholder's influence on the decision-making. For instance, patients may pressure the HCP to gain certain services without a justified medical reason. Moreover, due to the lack of direct financial liability on the policyholder, and the highly competitive market, HCPs tend to take this risk to maintain customer satisfaction.
In January 2014, the Saudi health council and insurance 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 studied 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 HCPs in the market 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 change to adopt 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. Currently, HCPs are facing technical challenges to fully onboard claims to NPHIES ecosystem which open the opportunity for FHIR-compatible HIS vendors to enter the Saudi health technology market.
Contractual terms and policies govern the reimbursement process, which includes pricing, communication standards, prior authorization policies, financial considerations, etc. However, local HCPs believe that translating these terms into effective operational procedures is challenging, expensive, and potentially restrictive. After qualitatively examining claims, we found that 2.9% of the studied health claims lacked adherence to medical policies.
This issue was more prevalent among busy HCPs with poor internal processes. However, NPHIES ensures current and accurate data transmission for instant validation.
The policyholder may consume more benefits than the policy allows, which may creates a reason for denial. Consequently, we found that HCPs rely heavily on requesting for prior authorization to mitigate the risk of claims rejection.
When adjudicating claims, some of the major insurance companies in the Saudi consider patient safety as a denial measure. For example, prescribing an intravenous antibiotic without proper indicative documentation or co-administering multiple drugs with potential harmful interaction are the bases for many denials.
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 claims’ quality versus timely monthly filing.