- Lack of expertise in insurance billing and medical coding, poor reporting and human error lead to huge revenue losses for HCPs, which adds to inflation in healthcare costs
- On average 15% of hospital revenue losses are caused by inaccurate and non-compliant reporting and billing submitted to insurance companies
Dubai: Healthcare bills are inflating at the rate of around 13% every year in the UAE. Pulse Holding, a UAE-home grown holding company for several healthcare brands, has announced the launch of Santechture, an innovative company, and Knwbility, a knowledge transfer solutions’ network for Revenue Cycle Management (RCM) that will enable healthcare providers (HCPs) to plug revenue losses and redirect a healthy flow of investment to the sector.
Revenue Cycle Management is the financial process used by hospitals and clinics to submit their patients’ insurance claim forms to insurance companies to request reimbursement of the services provided to patients. HCPs work closely with insurance companies to ensure patients get the best available treatment for their conditions. However, to claim the amount for the service provided to patients, HCPs are required to file the diagnosed condition and medical, surgical, or diagnostic procedure conducted along with the respective medical codes and the total amount. With different international coding systems, comprising each around 80,000 codes for various diagnoses and procedures, the accuracy of the codes provided in insurance claims is prone to human error and complexity.
As a result, insurance companies deny or reject numerous submitted claims, and providers have to bear the costs for the services offered to patients. This translates into significant revenue losses, and often puts pressure on providers to resort to non-protocol led treatment pathways that can carry unnecessary testing and investigation to retrieve lost revenues, or can subject the patient to additional unneeded diagnostics in an attempt to be on the safe side and comply with payers’ protocols to secure payment. Providers, who are subject to a high denial rate, are then often removed from insurance networks, thus affecting access for patients to those providers.
To this end, Pulse, who previously launched ACCUMED the first largest outsourced Revenue Cycle Management company in the region, has launched Santechture and Knwbility, two solutions aimed at preventing revenue leakage for HCPs. Dr Ayham Refaat, Founder and Managing Partner at Pulse Holding said, “Having been engaged with payers and providers for over fifteen years, we see that there is a gap in compliance, trust and understanding between both stakeholders. We are uniquely positioned to understand the need to address rising healthcare costs and strengthen the relations between HCPs and payors to shape the healthcare sector into a more sustainable and trustworthy industry. HCPs have a valuable opportunity to rectify their incompliance with insurance companies’ coding systems and plug revenue losses. Our objective is to help them improve their revenue integrity and compliance with insurance companies by driving protocol-based healthcare methods and accurate and compliant reporting and billing, ultimately leading to more accurate diagnoses and a trust-based relationship between patients, insurance firms and HCPs. This creates a win-win situation for every stakeholder in the industry.”
Santechture is a company that has developed a number of technology solutions, including a software-based verification system, which can be embedded within all or specific stages of the RCM journey. The technology is able to identify the integrity of claims before being submitted to insurance companies, enabling HCPs to provide better diagnoses and reduce revenue losses due to inaccurate coding.
Anas Batikhi, Vice President of Technology at Santechture said, “Santechture is an exciting state of the art technology for HCPs that will transform the RCM process and system. Santechture allows HCPs to keep the billing process internal, without feeling the need to outsource it, whilst increasing efficiencies, quality of documentation and creating a more sustainable ecosystem for them. It helps improving their revenue integrity and plugging their revenue losses caused by inaccurate billing. To bring this in context, healthcare spending in the wider Middle East and North Africa is expected to reach $144 billion by 2023. Imagine HCPs losing 15% to more than a third of this revenue, which alternatively could have been used towards maintaining key services, such as highly specialised oncology consultants or investment into cutting edge equipment.”
Pulse Holding has also launched Knwbility, a training academy, aimed at empowering clinical and billing teams with the knowledge and skills to reduce human error in coding and ultimately claim rejections, in order to optimise revenue integrity.
Medical coding refers to the codes used by healthcare practitioners to record each diagnosis, treatment and the value of the treatment. These codes are often, due to legacy IT systems or human error, misrepresented in claims sent to insurance companies when requesting reimbursement of the treatment rendered. 40% of claim denial is due to administrative error, whilst 60% is due to inconsistencies in clinical documentation. This is the case when doctors don’t document a diagnosis or episode of care correctly, and billing staff don’t translate it into the accurate code, due to lacking coding training and certification or human error. As a result, it generates misalignment between the documented patient’s diagnosis and treatment plan, which leads to compromised clinical data at a national level. Many HCPs lack training in coding, don’t hire certified and experienced coders, and don’t have the appropriate technology or quality assurance checks to ensure accuracy of coding. This means margin for error is large and data integrity reported at a national level is incorrect.
Ayman Ibrahim, Senior Director for Knwbility Academy said, “Knwbility provides certification in the UAE and wider region for clinical and coding staff to hone the knowledge and expertise, in an easy-to-access online training course, of the various international coding systems used by insurers and regulators in the local markets. Our expertise in the sector has given us the ability to formulate a bespoke course in billing that can empower 80% of the skills required for a coder to become well-versed with local billing protocols. We estimate that in the next decade, there will be a huge demand for medical coders in the GCC, with Oman and KSA alone requiring 22,500 coders. Knwbility plans to meet 90% of this demand and support the realisation of the national agendas of governments in the region that are committed to developing human talent.”
Ten years ago, Pulse Holding introduced ACCUMED, a company that managed the entire billing process of healthcare providers in the region, who sought to outsource their RCM process. The outsourced solution has since been able to save revenue from over $1.5bn claims submitted by providers.
The launch of the two companies taking place during the 19th IFHIMA International Congress, aims to empower Health Information Management Professionals through a global voice.© Press Release 2019
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