Student Dissertation

Agency : Health Insurance; Six Sigma; DMAIC Tool; High Risk Insurance Companies

Objective : To identify the reasons and rate of rejection for medical claims in Thumbay Hospital, Ajman. To apply Six Sigma DMAIC tool for analysis and suggestive measures to reduce rejection rate of medical claims in Thumbay Hospital, Ajman

Background : Standards of healthcare in the UAE are very high. Without a comprehensive medical insurance plan is not only risky, but can be very costly. Identified as a priority sector by the UAE government, the UAE health sector has displayed extraordinary growth and significant progress in medical insurance of their population. The health insurance industry has assumed a new dimension of professionalism with TPAs. It is very important for the healthcare providers to be able to process claims with this exponential expansion of health insurance swiftly and economically in UAE. Therefore, quantification of the denial rates by the healthcare providers is critical to calculate the effectiveness of your revenue cycle management processes and medical reimbursement. The denial rate represents the percentage of claims denied by payers during a given period. A low denial rate indicates cash flow is healthy, and fewer staff members are needed to maintain that cash flow. A 5% to 10% denial rate is the industry average; keeping the denial rate below 5% is more desirable as per the American Academy of Family Physicians. Unexpected uptick in denials and rejections of medical claims are a major cause of lost revenue for healthcare providers in UAE. Maintaining a high clean claims rate requires attention to detail at every step of the patient journey, and having good medical billing tracking HIMS for a positive difference. Finances obtained from the medical claims are the major source of income in UAE health sector and hence the reflection of functioning of insurance department in the hospital. Thumbay Hospital, Ajman is a world-class medical institution offering quality and affordable specialized superior medical care complemented by a warm and personalized human touch to the members of most of the insurance companies in UAE. The Insurance department of the hospital has 43 Insurance companies on direct billing. The past few quarters of financial year in 2015 suffered high rejection from insurance companies and no sufficient report or analysis was done in the hospital to figure out the reasons. Hence the need to map the process, analyze the reasons and streamline the process was felt, and the study was proposed to be conducted.

Methodology : A Qualitative Retrospective Study was carried out on the insurance department in Thumbay hospital; Ajman. The study was on claims processing of the patients who have the health insurance policy for out-patient, inpatient and pharmacy services. 5566 medical claims from September to October 2015 (last financial quarter) were included. These medi-claims were collected from accounts department and HIMS of Thumbay Hospital, Ajman. The collected data will be analyzed using simple statistical methods and Six Sigma DMAIC tool.

Findings : It was analyzed that there are 5 high risk insurance companies which faced the maximum rejection rate for 5 departments which were Internal medicine, Obstetrics and Gynecology, Pediatrics, general surgery, and Emergency

Recommendations : Since the reasons of high rejection rate were identified, methods to improve the process and streamline it were suggested. A proper up gradation in the HMIS system of the hospital could reduce the rejection rate drastically. There should be a proper training manual for the insurance front desk staff with all the inclusion and exclusion criteria for all companies so that if becomes easy to understand approval requirements. Doctors should also be informed about the general insurance policies and the medical claim requirements. All these changes when incorporated could help in reducing the rejection rate.