Showing 10 results for Insurance
R Safdari, R Sharifian, M Ghazi Saeedi, N Masoori, Zs Azad Manjir,
Volume 5, Issue 2 (9-2011)
Abstract
Background and Aim: Annually, large amounts of fees that paid by hospitals will not be reimbursed as deductions by health insurances and takes irreparable financial losses to hospitals. The purpose of this study was to determine the amount of deductions imposed on hospital bills of Tehran University of Medical Sciences and their causes related to documentation.
Materials and Methods: The present research was a cross-sectional and descriptive study performed in year 2009 on educational hospitals of Tehran University of Medical Sciences. All deductions reports related to Medical Services and Social Insurance related to year 2008 was collected from Income Unit of hospitals. The amount of deduction of each hospital was extracted and organized in the form of comparative tables. Data was analysed by descriptive statistics and Excel application. Then, the amount, type and causes of annually deduction of each hospital was determined.
Results: Most deductions imposed on inpatient bills have been related to the tests, appliances, medicine, residency, surgeon commission, and anesthesia and for outpatient bills have been related to visit, tests and medicine which most of them have been created due to documentation deficiencies.
Conclusion: Most of deductions are due to unfamiliarity of care staff with documentation requirements of insurance organizations. Therefore it is necessary to use a multi-aspect mechanism including education of documentation principles to staff, supervision on record control in the Medical Record Unit and establishment of a committee by university for related activities.
Mahmoud Keyvanara, Saeed Karimi , Elahe Khorasani, Marzie Jafarian Jazi ,
Volume 8, Issue 4 (11-2014)
Abstract
Background and Aim: The hypothesis of supplier induced demand has attracted a lot of attention over the past three decades. Most studies in this field agree that healthcare providers have the ability to influence the demand for their products. The purpose of this study is to evaluate the role of institutions in the phenomenon of induced demand. This study has been done using experts' experiences in Isfahan University of Medical Sciences.
Materials and Methods: This is a qualitative study in which the semi-structured interview was used for data generation. The participants were those informed in this regard and considered as experts. For data saturation, purposive sampling was done. In this study, 17 people were interviewed, and criteria such as reliability and stability were considered. The anonymity of the interviewees was guaranteed. The data were transcribed and categorized, and then analyzed using thematic analysis.
Results: In the present study, thematic analysis was conducted and 30 sub-themes and 2 main themes were extracted. The two main themes were healthcare insurance organizations and other health organizations. Each of the themes had its own sub-themes.
Conclusion: The findings help health policy-makers have a better picture regarding the role of various institutions in the phenomenon of induced demand.
Reza Safdari, Marjan Ghazi Saeedi, Mostafa Sheykhotayefe , Mohammad Jebraeily, Seyedeh Sedigheh Seyed Farajolah, Elham Maserat , Roya Laki Tabrizi,
Volume 11, Issue 1 (5-2017)
Abstract
Background and Aim: The most important issues that always absorb accuracy and effort of hospital, is the mastery and control over the financial status for the hospital resources management. In all countries, the medical centers are considered as a vital community resource and must be managed in line with the interests of society. Hence, these studies aimed to investigate the causes of insurance deductions and were made to assist hospital administrators in reducing the deductions against them.
Materials and Methods: This descriptive research is retrospective study in year 2012. The study population consisted of 100 insurance experts deployed in insurance centers (including Health care’s, Social security, Armed forces, Help Committee) from which 25 experts were randomly selected from each Insurance Center. Researcher madden questionnaire was used to collect data. For validating of questionnaire justifiability, questionnaire was provided to insurance expert, professors and ambiguities were resolved. Test-retest procedure was used to ensure the Stability of the questionnaire. The collected data was analyzed and classified using Excel software.
Results: These findings indicate that between all parts of surgery wards deductions are the highest (%45/55), and between surgery wards, orthopedics surgery had the highest amount of deductions (%40/75).
Conclusion: Healthcare provider should be more careful and minimize documentation errors in reporting and documentation. Also the hospital administrators for reducing deductions against patient records must provide educational course for correct documentation.
Maryam Nakhoda, Abbas Sheikh Taheri, Madihe Esfandiari Pour,
Volume 11, Issue 1 (5-2017)
Abstract
Background and Aim: Organizations must collect, process and analyze different types of necessary information and give them to managers and other individuals. Such information includes the management of medical records and documents in insurance companies. This study aims to evaluate the potentialities of medical records management electronic systems in such companies.
Materials and Methods: In this cross-sectional applied research, the systems existing in insurance companies were checked using researcher-made checklists to study the capabilities of medical records management electronic systems in all governmental and private insurance companies of Gorgan. For data-analysis, descriptive statistics (frequency, percentage) was used.
Results: In data register and entry, the share of insurance companies as well as the amount of deductions was 92%. In the ability to search, store and retrieve, the search based on the names of persons had the highest percentage (100%). Security was one of the features considered in the software of insurance companies. In the reporting section, the possibility to report the titles of medical documents was 92%. Lack of physical and electronic documents manageability through check-out method was 14%.
Conclusion: In terms of functional capabilities, softwares observed in insurance companies have both strong points (security feature) and weak points (classification and indexing capabilities). The management of medical records and documents can be enhanced in the softwares of insurance companies by using the mentioned capabilities of the existing softwares.
Mohammad Arab, Ebrahim Jaafari Pooyan, Abbas Rahimi Forushani, Azam Sadat Rivandi,
Volume 12, Issue 2 (7-2018)
Abstract
Background and Aim: The quality of healthcare services is determinant in patients’ improvement process, upgrading their satisfaction, ranking healthcare centers, and preventing patients’ repeated referrals leading to more costs for healthcare centers and insurance companies. The purpose of this study was to evaluate the quality of services -- from the perspective of patients -- given by the laboratories having contract with Iran Health Insurance Organization (IHIO).
Materials and Methods: In this cross-sectional study, the opinions of 302 patients having referred to the laboratories in contract with IHIO in Tehran were surveyed with a researcher-developed questionnaire. Descriptive and inferential statistical tests were used to analyze and report the results.
Results: The sample included 43.5% males and 56.5% females. Most of the participants were married (71/3%). Based on the results, the patients' perception of the quality of laboratory services was 78%. Their expectation of services was 85%. The gap between perception and expectation of clients in all dimensions was statistically significant (p<0/001).
Conclusion: The gap between clients’ perception and expectation in all dimensions suggests that there is some room for improving the quality of laboratory services. The results of this assessment can surely affect the way IHIO treats with laboratories in terms of extending contracts and strategic purchase of services from these centers. In addition, patients' opinions will be important in improving the quality of services.
Mohammad Tasavon Gholamhoseini, Mohsen Barouni, Nooshin Afsharzadeh, Mohammad Jafar Isirizi,
Volume 12, Issue 4 (11-2018)
Abstract
Background and Aim: One of the common problems of children all over the world is short stature. Due to the high costs of treatment, the present research studied the cost-effectiveness of growth hormone (Somatropin) for the treatment of children with short stature in Kerman Province.
Materials and Methods: This research is an economic evaluation. The population of the study consisted of all persons who had medical records in the health insurance office of Kerman province, of whom 49 were selected as samples. The cost was calculated from the perspectives of patients and insurers. This information was collected through a researcher-made form by interviewing the patients and reviewing the records of health insurance office. To calculate the outcomes, QALY and Increase in Height were used. For cost effectiveness analysis, the ICER formula and TreeAge software were employed and compared with a threshold of 3 times GDP per capita.
Results: The findings showed that the share of patients' treatment costs was 5,092,964,520 and the expenses of Health Insurance Organization of Kerman province was 71,175,443,448 rials. Based on Qaly criterion, incremental cost-effectiveness ratio was 743,133 and 9,846,567 rials from the perspective of the patient and of the health insurance organization, respectively. Sensitivity analysis of non-deterministic parameters of the model showed that they had no effect on the cost-effectiveness of treatment with growth hormone.
Conclusion: According to the results, the treatment of short-stature children with growth hormone is cost-effective, and this result can be considered by health system policy makers.
Eng. Meisam Fallahnezhad, Reza Safdari,
Volume 15, Issue 3 (8-2021)
Abstract
Background and Aim: Large amounts of hospital costs are not reimbursed annually by health insurance as deductions. Therefore, reducing deductions is very important for the hospital. In the study of design and implementation of analytical dashboard of insurance deductions based on medical intelligence business, to improve financial management with the aim of focusing on assessing the level of satisfaction and its applicability has been done.
Materials and Methods: To design the questionnaire, first 27 questions were prepared through library studies and interviews with members of the hospital board of directors, and the validity and consistency of its items were determined through content validity and Cronbach’s alpha coefficient. Data were analyzed in SPSS software and the results were used to design and implement the dashboard.
Results: The study is of development-applied type. In the first phase, to determine Content Validity Ratio CVI (Content Validity Index), and CVR (Content Validity Ratio) a researcher-made questionnaire was provided to 20 experts. In the second phase, by building a data warehouse in SQL (Structured Query Language), the information of the tables related to the deductions of the hospital HIS system was transferred to it and the operational information of the organization was extracted and converted into DW format and the map information was tested. OLAP (Online Analytical Processing) services were then loaded on the created analytics database. In the last step, Power BI tool was selected and used to create business intelligence mechanisms, display and visualize information. In the third phase, using the QUIS (Questionnaire for User Interface Satisfaction) standard questionnaire, the level of satisfaction and usability of the dashboard was evaluated by 15 experts.
Conclusion: In this study, two questionnaires were used. CVR was measured in all items of the first questionnaire, more than 0.50 and CVI was measured in the upper areas of 0.90 and Cronbach’s alpha coefficient was obtained between 0.8 and 0.9, which indicated a good level. The second questionnaire was to evaluate the level of satisfaction and usability of the dashboard that the average of the total evaluation based on the indicators of the QUIS questionnaire is equal to 85.40. Therefore, the level of satisfaction and usability of the dashboard was “very good” for the evaluators.
Mohamad Hoseini Kasnavieh, Mahsa Mahmoudinejad, Mohammad Veisy, Pouya Hedayati Shahidani, Ali Tahmasebi,
Volume 16, Issue 5 (12-2022)
Abstract
Background and Aim: this study aims investigating the effect of the physician's presence on the error of recording surgical codes by surgical assistants and the resulting financial effects in Rasoul Akram hospital.
Materials and Methods: The present study was a descriptive-analytical and prospective study that was performed by collecting data in the hospital and reviewing the documents from Jun to March 2022. Therefore, in order to compare the deductions according to the presence or absence of the doctor, an expert was stationed in the operating room to enter the information in special forms, and thus the types of deductions for each of the mentioned situations were identified. T-test was used for analysis between the two groups (presence and absence of physician) and data were analyzed using Excel and SPSS software.
Results: Three hundred and one records were reviewed during the presence of the physician and 300 cases during the absence of the physician based on Cochran sampling formula. The percent difference between hidden deductions in the presence and absence of the physician was not significant (P-value=0.078). However, the difference between the obvious deductions in the presence and absence of the physicians was significant (P-value=0.024). The difference in obvious deduction costs was significant in the presence or absence of a physician (P-value<0.001). But, the difference in hidden fraction costs in the presence or absence of physicians, was not significant (P-value=0.435).
Conclusion: The presence or absence of a surgeon has an effect on the amount of errors in the registration of surgical codes by the surgeon’s assistant and, as a result, this matter affects the percentage and costs of surgical deductions, especially in the obvious deductions. Therefore, planning for the presence of the surgeon in cases where the error of registering the codes by the surgeon’s assistant leads to obvious deductions, can help to more accurate documentation and, as a result, fewer deductions are accrued.
Azra Daei, Mohammad Reza Soleymani, Hasan Ashrafi-Rizi,
Volume 17, Issue 6 (2-2024)
Abstract
Background and Aim: The role of information in improving the health of society and reducing healthcare costs is undeniable. However, in practice, there exists insufficient and incomplete information among healthcare providers. This lack of comprehensive information among market players leads to inefficiencies and failure in market performance. The main goal of the current research was to investigate health information asymmetry and inadequacy within the health information market.
Materials and Methods: This article is a narrative and unsystematic review. Studies were retrieved from the Scopus, PubMed, Web of Knowledge, Magiran, Sid and Google Scholar databases by using the keywords of information inadequacy, Asymmetry of health information done in the fields of article title, abstract and keywords. Subsequently, according to the purpose of the study, the researchers selected relevant resources and summarized their findings.
Results: 18 paper were selected for this research. In this research, we specifically address health information inadequacies across three key sections: patients, doctors, and insurance. At the end of each section, ways to solve these deficiencies were mentioned. Results Showed patients faced with the phenomenon of injustice in accessing health information, and the continuation of this injustice leads to the poverty of health information, and due to the lack of proper access to health information, the asymmetry of information between the doctor and the patient was created. Doctors, on the other hand, faced challenges in accessing up-to-date and evidence-based information for patient care. Asymmetric information could be exploited, resulting in induced demand. Insurances face the problems of inappropriate selection, moral hazard and demand induction by the supplier or consumer.
Conclusion: Information asymmetry has seriously penetrated the health field and there is a high level of unconfident and uncertainty in it. One of the ways to overcome the health information asymmetry and insufficiency of the health information market is the access of all stakeholders to the information.
Ali Mohammad Mosadeghrad, Mahdiyeh Heydari, Mahya Abbasi, Mahdi Abbasi,
Volume 18, Issue 2 (12-2024)
Abstract
Background and Aim: Health insurance organizations play an important role in increasing people’s access to health services and protecting them financially against catastrophic health costs. Iran Health Insurance Organization (IHIO) is one of the largest public health insurance organizations in Iran, which faces many challenges. The purpose of this research is the strategic analysis of health financing performance of IHIO.
Materials and Methods: This qualitative research was conducted using interpretive phenomenology method through using semi-structured interviews with 25 managers and employees of IHIO. In addition, relevant documents and archival data of IHIO were collected and analyzed. Thematic analysis method was used to analyze the data.
Results: Overall, 19 strengths, 24 weaknesses, 14 opportunities, 37 threats and 43 solutions were identified for the health financing system of IHIO. Increasing the coverage of health services, correcting the information databases of the insured and electronic prescribing were the most important strengths, and inappropriate pooling of financial resources, incomplete risk pooling, high administrative costs, and inefficient control were the most important weaknesses of IHIO. The most important opportunities for IHIO include the government’s support for universal health coverage and emphasis on primary health care, legal support for consolidating health insurance funds and improving the health technology assessment system in the country. The main threats to IHIO include political and economic unstability, low health insurance premiums, decisions without scientific support and insufficient enforcement of laws. Finally, solutions such as modernizing the tax system, increasing the health literacy of the community, reducing bureaucracy, increasing transparency and accountability, and reforming the monitoring and evaluation system were identified to strengthen the performance of the financing system of IHIO.
Conclusion: Iran’s health insurance organization is facing numerous structural, contexual and process challenges that have reduced its productivity. Decrease in revenues, increase in costs and decrease in efficiency have caused problems in the financing performance of this organization. Recognizing the weaknesses and challenges of financing performance and applying corrective interventions is the first step in strengthening the sustainability of health financing of IHIO.
