Student Dissertation

Agency : Root Cause Analysis; Medical Claims; Health Insurance; Rejection Rate; Claim Management

Objective : The department is staffed by a team of expert professionals who assist in administering to the needs and queries of patients holding insurance cards The aim of the study is to develop an understanding of the process flow of insurance department, the claim management and analysis of rejection rate A Qualitative Retrospective Observational Study was carried out on the insurance department & claims processing of the patients who have the health insurance policy both in-patient & out-patient.

Background : After the process of approval request and claim processing, the invoice/bill that are generated are submitted to insurance companies. By verifying policy terms and conditions, insurance companies send the request back by rejecting the amount not justified and the reason of rejected amount. The reconciliation team verifies the reasons and replies back with the proper justification to reconsider the rejected amount The average rejection rate before reconciliation is 5.1%, and the rejection rate after the process of reconciliation is below 2%.the reasons for rejection were analyzed and found that rejections due to billing errors are found to be more then medical reasons Out of medical reasons services not justified was found the major reasons where as in billing reasons- pricing not as per agreed tariff is the major reason. Fish bone analysis is done to identify root causes of rejection of medical claims. Process improvement is targeted through Documentation of Manual which includes basic information related to contact details types of card Services requiring preapproval, Insurance company limit, and Policy coverable and non coverable and validity period of services. Upgrading HMIS of Billing section with mandatory entry for coins & deductible, Orientation & training of staff .Clear and detailed information of patient condition in medical records. there should be a format of explaining medical condition to reduce the errors of services not justified. Token system and queuing of patients is necessary to reduce the workload on staff and waiting period of patients. Rejection rate are the important measures for insurance department in a hospital. As per IRDA any hospital having rejection rate less than 2% is considered to have good practice of claim process management. Hence process improvement to reduce rejection rate should be implented.