Study reveals cost of dispute in medical claims

Dubai: Physicians in the UAE request anything from two to 12 medical diagnostic tests for diabetes, resulting in an increasing number of disputed medical claims, according to a study released on Thursday.

The 2011-12 study reveals that over 8.6 per cent of submitted claims – for conditions like diabetes, hypertension, anaemia, thyroid disorders and Vitamin D deficiency - from private hospitals were disputed by insurance companies and healthcare providers.

The study analysed 598,000 insurance claims totalling to Dh263 million, of which the disputed amount was Dh20.4 million.

During a media round table the findings of the AccuMed PM study, which surveyed 10 healthcare providers in the UAE, were made available.

The primary reason for the disputed claims is lack of unified clinical pathways as healthcare providers choose different methods and frequency to diagnose the same condition.

The study further posits that unified clinical pathways and electronic medical records (EMR) will reduce the percentage of disputed medical claims.

Speaking to Gulf News, Dr Ayham Refaat, founder and managing director, AccuMed PM, a healthcare management company in Dubai, said that the study sheds light on the issue of disputed claims and the absence of consensus on clinical pathways for common treatment.

“I was surprised by the big figure [of disputed claims],” he said.

When asked whether the figure of 8.6 can be compared regionally and globally, Dr Refaat said that it isn’t possible. Regionally there is lack of centralised data. It would be unfair to compare the UAE with countries like the US because the health system operates on different parameters, he said.

The study recommends government-level participation. “We need consensus on best practice to prevent the differences in the cost of medical insurance claims. We also need centralised data so it can be audited to improve medical care while ensuring it is cost effective,” said Dr Refaat.

He added, the study will be published in a White Paper.

In May, the Dubai Health Authority (DHA) launched the Health Accounts System of Dubai (HASD) which collates financial data – collected from healthcare providers and insurance companies across the government, semi-government and private sectors, and residents to help policymakers understand the country’s health systems. The first report is expected by year end.