Market experts regard the Saudi private healthcare sector as one of the largest markets in the region, with a market size of 34 billion SAR. Within this market, health insurance companies are responsible for generating 53% of the total annual revenue. By 2030, the Saudi national transformational plan aims to gradually increase the market size by more than 141 billion SAR via a privatization plan. However, the relationship between providers and payers is not as

transparent or standardized as in other global markets. Such limitations negatively affect the market’s growth rate and fair market dynamics among stakeholders. Furthermore, the average claims rejection rate is estimated to be around 15-25%.

After conducting an intensive 6-month market study, Glance Care’s team highlights within this article some of the market’s dynamics, regulators’ rules, challenges, and available solutions.

Study Sample Size

Study methodology: Structured interviews and qualitative/quantitative claims data analysis.

1. Medical case/claim lifecycle in the Saudi healthcare system

The medical case/claim lifecycle starts with case registration, with most cases being walk-in. Initially, the triage team classifies the case into non-urgent or urgent admission. In the case of non-urgent conditions, the healthcare provider (HCP) reviews the policyholder’s eligibility, benefits, and co-pay, whereas urgent cases are lawfully entitled to service without checking for eligibility.

Sequentially, the HCP delivers services and documents the encounter’s events, services, and justifications.

Then, the HCP’s billing team ensures complete invoices/claims files, compliance, and timed submission.

Lastly, the payer adjudicates claims and presents an initial settlement offer. As a response, the HCP’s billing team may accept and collect payment or negotiate for better reimbursement rates. This is usually a 1–5-month process after claim submission.

2. Common reasons for medical claims rejections/denials in the Saudi market

2.1 Lack of medical necessity or appropriateness of care

Medical necessity adjudication is a complex process, especially in the local market. It is primarily due to the lack of standardized medical documentation and clinical practice guidelines. Ideally, medical claims should service a welldefined diagnosis/problem as a clear justification. However, most of the local medical practitioners have been trained to rely on exploratory testing to formulate an understanding that has shown to be cost-ineffective—as a result, submitting a claim with an inaccurate or inappropriate diagnosis mostly leads to a denial of excessive or unnecessary service. Using GlanceClaim Checker, 40.5% of the studied health claims lack appropriate justification.

2.2 Policyholder influence

One of the uniquely disruptive factors that affect the medical claim quality is the patient/policyholder’s influence on the decision-making. For instance, patients may pressure the HCP to gain certain services without a justified medical reason. Moreover, due to the lack of direct financial liability on the policyholder, and the highly competitive market, HCPs tend to take this risk to maintain customer satisfaction.

2.3 Low-quality medical documentation

In January 2014, the Saudi health council and insurance council mandated the Australian coding standard for inpatient encounters. However, it has been challenging to implement this change due to insufficient medical coding personnel. We found that 27.8% of studied claims suffered from coding errors.

2.4 Non-compliance with the minimum data set

Medical claim filing in Saudi Arabia follows specific standards and requirements appointed by the local regulator, i.e., the Saudi Council of Health Insurance (CHI), to ensure adequate and fair claims processing/reimbursement. Standards include utilizing the unified claim and approval form (UCAF / DCAF 2.0) and the claim’s minimum data set (MDS v3.1). Failure to comply with these requirements jeopardizes the claim’s integrity and fair reimbursement. We found that most HCPs in the market are not fully compliant. Financial limitations, operational restrictions, and technical immaturity played a major role.

2.5 Technical limitations

Accurate transmission of data between stakeholders is one of the most significant challenges in the Saudi market. The reason for this appears to be a lack of standardized data transmission protocols. However, the new regulatory change to adopt the National Platform for Health and Insurance Exchange Services (NPHIES) standards, which are a local modification of HL7-FHIR standards, will significantly improve the market’s technical infrastructure, allowing for greater interoperability and better data exchange. Reflecting on the sampled EHR systems, 2 out of 3 are non-compliant with the minimum data set (MDS v3.1) requirements due to limitations in the system’s data architectural design. Currently, HCPs are facing technical challenges to fully onboard claims to NPHIES ecosystem which open the opportunity for FHIR-compatible HIS vendors to enter the Saudi health technology market.

2.6 Non-adherence to the payer or national unified medical policies

Contractual terms and policies govern the reimbursement process, which includes pricing, communication standards, prior authorization policies, financial considerations, etc. However, local HCPs believe that translating these terms into effective operational procedures is challenging, expensive, and potentially restrictive. After qualitatively examining claims, we found that 2.9% of the studied health claims lacked adherence to medical policies.

2.7 Invalid membership

This issue was more prevalent among busy HCPs with poor internal processes. However, NPHIES ensures current and accurate data transmission for instant validation.

2.8 Consumed and exhausted benefits

The policyholder may consume more benefits than the policy allows, which may creates a reason for denial. Consequently, we found that HCPs rely heavily on requesting for prior authorization to mitigate the risk of claims rejection.

2.9 Medically harmful services

When adjudicating claims, some of the major insurance companies in the Saudi consider patient safety as a denial measure. For example, prescribing an intravenous antibiotic without proper indicative documentation or coadministering multiple drugs with potential harmful interaction are the bases for many denials.

2.10 Late filing

With the overwhelming daily operations, submitting claims on time is one of the HCP’s most stressful tasks. Without supportive workflow, infrastructure, and policies, HCPs continue to trade between claims’ quality versus timely monthly filing.

3. Solutions

It is reasonable to instinctually DIY a solution when you identify the reason for a systematic weakness. However, it may not always be directly applicable or scalable. We found that most HCPs have tried to optimize or resolve claims denial reasons. However, most of the studied HCPs faced implementation challenges and lack of operational, and financial flexibility. The complexity of the medical claims management process and the hospital workflow deem most manual interventions unsustainable. Moreover, the lack of a cultural mindset within the organization undermines applicability and sustainability.

Glance Care team had identified three leading solutions in the Saudi market, consultation/training-based solutions, operation-outsourcing solutions, and technology-based solutions.

3.1 Healthcare consultancy services

They support business evaluation, strategy planning, technology implementation, revenue cycle management, etc.

3.2 Outsourcing services or functions

Act as long-term third-party partners to overtake certain operational functions. They tend to be on-shore or off-shore teams. One of the most prominent examples in Saudi is revenue cycle management companies. Such solutions enable care providers to focus on clinical-related services and reduce administrative burden.

3.3 Technology-based solutions

Software solutions provide services with well-defined functions. These enable HCPs to automate and standardize specific processes to achieve their targeted goals.

Example

1. Claims auto-checkers

2. ICD10 coding systems

3. Authorization & eligibility verifiers

4. Suggested Best Practices

1. Continuous claims evaluation and diagnosis of denial reasons

2. Optimize the workflow to identify and fix claims issues faster and more cost-effectively

3. Communicate and collaborate with payers to reduce rejections/denials

4. Engage all stakeholders in the process of improving claims quality

References

1. https://www.sama.gov.sa/ar-sa/Insurance/Pages/Publications.aspx

2. https://www.cchi.gov.sa/OpenData/Documents/2020.pdf

3. https://www.aleqt.com/2020/02/10/article_1760166.html

4. Alonazi WB. Fraud and Abuse in the Saudi Healthcare System: A Triangulation Analysis. Inquiry.2020;57:46958020954624. doi:10.1177/0046958020954624

5. https://www.statista.com/topics/4807/healthcare-in-saudi-arabia