Doctors over-charging? Dh20m 'disputable' bills
Medical billing of almost Dh20.4 million has been found to be disputable as many medical institutions across the country continue to prescribe unnecessary tests
According to a recent study conducted by AccuMed, a practice management company, mostly in private hospitals in Abu Dhabi and Dubai, about 8.6 per cent of all claims that were submitted were found to be disputable between the insurance companies and healthcare providers.
Most of the claims were related to diagnose or to rule out diabetes, hypertension, anemia, thyroid disorders and Vitamin D deficiency. Dr. Ayham Refaat, Founder and Managing Director of AccuMed PM, said the study looked at 598,000 insurance claims amounting to approximately Dh263 million.
“It is not just about money that we need to be concerned about. It is also a reflection of best medical practices,” says Refaat.
“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,” Refaat said.
The debatable amount he says reflects the inconsistencies in the number of tests performed and billed versus the ones paid for. “We also analysed an additional 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 Dh40.23 to Dh157.27 per case,” he argued.
According to 2011 statistics Dubai has about 1,100,000 people insured amounting to 6.8 million visits, while Abu Dhabi encountered about 11.4 million visits from 2,800,000 insured population. The total premium value in UAE amounts to Dh13,7 billion. (Estimated on pro rata basis to population)
AccuMed, whose clients are mainly hospitals and medical service providers is trying to reduce the growing area of dispute between payers and providers. According to Refaat, there is a need 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 standardisation 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,” Refaat added. “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.”
Another major problem in the GCC he says is 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,” Refaat added.