Government, healthcare providers and insurance companies should review ways to ensure that the delivery of quality healthcare services to patients is done based on cost-effective methods, says AccuMed PM
Dubai, UAE, June 20th, 2013: Different diagnostic procedures performed for similar medical conditions are leading to a significant amount of differences in the cost of medical insurance claims, a leading healthcare management company has pointed out.
AccuMed PM, a leading provider of innovative healthcare billing solutions, said the opportunity to understand trends through robust data analysis by key stakeholders, will improve patient experience, care and potentially save costs which in turn benefits all of us paying for insurance.
Pointing to an AccuMed PM case study that analyzed different procedures used to diagnose or rule out diabetes, hypertension, anemia, thyroid disorders and Vitamin D deficiency, Dr. Ayham Refaat, Founder and Managing Director of AccuMed PM, said that 0ver 8.6% of claims that were submitted were found to be disputable between the insurance companies and healthcare providers.
The study looked at 598,000 insurance claims amounting to approximately AED263 million, of which the disputed amount was AED20.4 million. The debatable amount reflects the inconsistencies in the number of tests performed and billed versus the ones paid for. As part of the same study, AccuMed analyzed further 25,844 cases of diabetes and found that the number of tests requested for the same diagnosis during the same visit ranged from 2 to 12 tests, with values ranging from AED 40.23 to AED 157.27 per case.
“The debate arises when there is no clarity on how healthcare providers choose different tests to diagnose the same condition and at the same time, it is not clear on what clinical basis insurance companies sometimes choose to pay for the test or reject it outright at other times, despite the fact that the diagnosis remained the same and only one,” Dr. Refaat told a conference in Dubai today.
Dr Refaat, a leading authority on medical billing, said that the definition of medical necessity is a growing area of dispute between payers and providers. He called for comprehensive data mining and trending analysis that were aimed towards the establishment and deployment of UAE-friendly unified clinical pathways that will determine the guidelines for diagnosis and treatment of medical conditions.
Clinical care pathways are medical guidelines that are based on evidence-based practices in which the different tasks performed by the clinicians involved in the patient care are defined, optimized and sequenced. This multidisciplinary management tool is vital to manage the quality aspect of healthcare in relation to the standardization of care processes. Such standardization reduces the variability in clinical practice and improves quality as it illustrates a structured and effective care map based on evidence based practice
“Having a predominantly insurance-driven focus might affect the financial sustainability of the region's healthcare sector, leaving insurance companies and healthcare providers to grapple with the actual costs of healthcare services,” Dr Refaat said. “Unless proper mechanism was put in place, the costs of these undecided treatments can have major financial repercussions on the region's healthcare system, affecting healthcare providers, insurance companies and government regulators.”
“Such case studies are some of the many trending analysis that can improve our understanding on how to effectively manage the UAE's healthcare market. Studies such as claim cost-benefit analysis, activity-based costing and utilization ratios, to name a few, undertaken by AccuMed PM have helped physicians and insurance companies to make informed decisions on quality of care, profitability and operational efficiency accordingly,” he added.
Another major problem in the GCC was the poor understanding of best practices and international guidelines in medical coding. Medical coding is the process of assigning codes to a patient's medical diagnosis and procedure descriptions which should be performed by certified coders and only after reviewing the clinical notes of the physician. Collecting and reporting aggregate information through codes allows the medical community a simplified way to provide data quickly along with making informed decisions.
“It is imperative to note that the desired outcomes of the data mining and trending analysis will not be realized without effective deployment of information technology tools that will ensure standardization of protocols and strict adherence to best practices,” Dr Refaat said.