Evaluation of Authentic and Non-Authentic Claim Rejections at Thumbay University Hospital, Ajman, UAE

STUDY TO EVALUATE THE AUTHENTIC AND NON STUDY TO EVALUATE THE AUTHENTIC AND NON- - AUTHENTIC CLAIM REJECTIONS AT THUMBAY AUTHENTIC CLAIM REJECTIONS AT THUMBAY UNIVERSITY HOSPITAL, AJMAN, UAE UNIVERSITY HOSPITAL, AJMAN, UAE Name : Dr. Navneet Kaur Pannu Faculty Mentor : Prof. Nishikant Bele IIHMR Delhi You are not allowed to add slides to this presentation 1

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Introduction Introduction Thumbay University Hospital is a Leading 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. This Department is staffed by a team of expert professionals who assist in administering to the needs and queries of patients holding insurance cards. Thumbay University Hospital is the largest private academic hospital in the Middle East region, with 350 beds. Amenities for patients and visitors include a multi-restaurant food court, movie theatre, coffee shops, health club, 1000+ free parking spaces etc. We are are part of the academic hospital network of Thumbay Group, which has a professional workforce of 30 different nationalities serving patients in 50 different languages and serving patients from over 175 nationalities. 3

Introduction Introduction A denial in insurance occurs when the health insurance company notifies that the proposed service treatment or medication will not be covered. It is a process that reduces the revenue of the hospital which is a threat in a long term process. This study focus on the claim rejection getting from the insurance companies by analyzing the authentic and non authentic claims rejection, also will understand the overall accuracy of the claim rejection , study will identify the core factors and common reasons received from the insurance companies, to evaluate the total percentage of authentic and non authentic claim rejections from insurance companies at TUH , Ajman, UAE 4

Objectives of Your Study Objectives of Your Study To understand the common reasons of authentic and non-authentic claim rejections received from the insurance companies at Thumbay University Hospital, Ajman, UAE. To evaluate the total percentage rate of authentic- non-authentic claim rejections given by the insurance companies at Thumbay University Hospital, Ajman, UAE. To understand the standard rate of claims rejections given by the top 7 insurance companies out of 24 Empaneled insurance companies at Thumbay University Hospital, Ajman, UAE. 5

Methodology Methodology RESEARCH DESIGN: TYPE OF DATA: The research design used in the dissertation was descriptive. Secondary data collection: Secondary data is collected from the insurance company replies is consolidated is taken. SAMPLE SIZE: SAMPLING TECHNIQUE USED: The number of claims for the year 2021 is 3652 at Thumbay University Hospital Complex. Purposive sampling technique was used in order to understand the reasons of rejection. 6

LITERATURE REVIEW LITERATURE REVIEW ARTICLE FRAUD CLAIMS REJECTION IN UAE HEALTHCARE SYSTEM Article author: Wadi B. Alonazi1 Article Published online 2020 Sep 25. In hospital industry majority of health insurance falls under false medical claims , yet false claims generally lead to negative effect on organization . through monitoring the reasons & factors for claim rejections found in health insurance industry , this study aims to analyze authentic & non- authentic medical claim rejection received from health insurance company , to accomplish this objective major health insurance medical denial codes with medical denial remarks were analyzed. Top seven health insurance companies at THUMBAY UNIVERSITY HOSPITAL ( TUH ) were undertaken to understand such rejections . the critical factors of authentic & non- authentic were analyzed using a descriptive analysis. Data were retrieved from hospital HIMS record of top ten health insurance companies , focus was mainly on seven health insurance companies which were involved with TUH for year 2021. After a full audit was completed , the result concluded that the UAE healthcare system is composed of thirty three health insurance companies on annual average more than 5068 non- authentic claims were reported with a medical claim rejection of 24%. The majority of rejection were received from Oman health insurance 7

Results Results COMPANY WISE TOTAL CLAIMS Claim status 7000 6000 6533 5000 4000 4477 2% 3000 2000 FULLY REJECTED 1000 1421 951 167 288 70 576 222 137 549 153 464 PARTIALLY RECEIVED 0 98% 8

Results Results Company wise Claim status Medical claim rejection code wise FULLY PARTILALLY 3000 2500 6000 2477 2000 5000 1500 5068 1000 4000 1019 500 631 16 268 103 379 127 25 57 140 377 65 254 3000 3248 0 ADNIC AXA DAMAN HEALTHNET MEDNET NEURON OMAN 2000 Types of Claim Rejection 1000 60 306 546 406.1 64 162 26 162 0 MNEC 003 MNEC 004 MNEC 005 MNEC 006 MNEC 007 24% 29% 47% Authentic Non-Authentic 9 BILLING BILLING AND MEDICAL MEDICAL

Results Results OMAN ADNIC 700 Authentic Non authentic 600 3500 587 500 400 2884 2845 300 3000 200 100 146 22.6 91 38 57 0 2500 MNEC 004 MNEC 005 MNEC 006 Authentic Non authentic 2000 Daman 1500 1200 1116 1000 1000 800 600 356 400 500 247 200 94 125 16.5 148 24 0 0 MNEC 004 MNEC 005 MNEC 004 MNEC 005 MNEC 006 AUTHENTIC NON AUTHENTIC 10

Discussion Discussion Study was done to evaluate the authentic and non-authentic medical claim rejections Authentic claims - authentic claims are those claims which are rejected by insurance company and the rejection done is valid and these claims are non-resubmitted due to medical reason or billing reason Non authentic claims- non authentic claims are those claims which get rejected through insurance company without valid reason and are resubmitted As per evaluation highest claim rejection received from Oman insurance company both for authentic as well as non-authentic , value of non-authentic rejection is high as compare to authentic rejection Out of 7 insurance company highest claims received from Oman, Daman & Adnic As per analysis these 3 insurance companies plays very important role for generating the revenue at THUMBAY UNIVERSITY HOSPITAL. 11

Discussion Discussion Reasons for Claim rejections are based on various medical denial codes, study focuses on 5 most repeated codes those are:- MNEC 003- Service is not clinically indicated based on good clinical practice MNEC 004- Service is not clinically indicated based on good clinical practice, without additional supporting documentation MNEC 005- Service/supply may be appropriate, but too frequent MNEC 006- alterative service has been used MNEC 007- Service is not clinically indicated based on good clinical practice, without additional supporting documentation CODE WISE REJECTION:- As per analysis highest claim rejection received for code MNEC 004 & MNEC 005 COMPANY WISE REJECTION:- Out of 7 insurance company highest claims received from Oman, Daman & Adnic As per analysis these 3 insurance companies plays very important role for generating the revenue at THUMBAY UNIVERSITY HOSPITAL. 12

Limitations of the Study Limitations of the Study Time was a major constraint for the analysis and review as it bound to academic time period which starts. The results cannot be generalized to other Healthcare Institute as it is conducted in TUH Ajman. Data collected was limited for the year 2021. Data available is secondary due to confidentiality norm You are not allowed to add slides to this presentation 13

Conclusion Conclusion As a conclusion, this report has been done to show the current insurance claim rejection. Authentic & Non authentic claim rejection, companies can manage the rejection by analyzing the core health related issues of their customers for which medical services is very important, claim rejection management will provide insurance with the management will provide insurance with the flexibility to offer tailored solution to their customer & better align customer needs with business objective with TUH. This improvement will ultimately boost key performance indicator which will definitely impact operating result in a positive way for both insurance company and TUH. 14

Reference Reference 1. https://usuaebusiness.org/wp- content/uploads/2015/09/HealthcareReport_Update_June2014.pdf 2. Reasons for Health Insurance Claim Denials and What You Should Do [Internet]. Verywell Health. [cited 2022 Jun 26]. Available from: https://www.verywellhealth.com/what- is-a-health-insurance-claim-denial-1738690 3. Health insurance claim rejected? These could be the reasons [Internet]. [Cited 2022 Jun 26]. Available from: https://www.hdfcergo.com/blogs/health-insurance/health-insurance- claim-rejected-these-could-be-the-reasons 4. Alonazi WB. Fraud and Abuse in the Saudi Healthcare System: A Triangulation Analysis. Inq J Med Care Organ Provis Financ. 2020 Sep 25; 57:0046958020954624. HealthcareReport_Update_June2014.pdf [Internet]. [cited 2022 Jun 26]. Available from: You are not allowed to add slides to this presentation 15

Any Questions Thank You You are not allowed to add slides to this presentation 16

Suggestions to the Organization where the Suggestions to the Organization where the Study was Conducted Study was Conducted Provide regular trainings to the working staffs regarding the updated protocols of the respective departments Meeting should be conducted with the insurance companies for any related queries to be settled Departments related to documentation like radiology and MRD should be informed for updating appropriate reports/documents You are not allowed to add slides to this presentation 17

Dissertation Experiences Dissertation Experiences What did you learn (skill/ topic)? Medical denial codes in insurance Process of resubmission and reconciliation. Managing rejection from insurance company. Managing medical part of insurance claim. Overall self comments on Dissertation Overall observation in the dissertation Insurance department plays a very crucial role in generating revenue for hospitals. Insurances is made Mandatory for all residents by UAE government. In UAE Insurance is booming sector which has great career opportunities. You are not allowed to add slides to this presentation 18

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