Addressing Health Insurance Deductions through an Interventional Study: the Case of a Large Central Hospital

Abstract

Objective: A large proportion of hospitals’ private income is provided by insurance organisations. Hospitals in Iran face various problems in terms of insurance deductions from insurance organisations resulting from inefficient performance by both the hospitals and the insurers. These problems necessitate more specific cost control in this area. This research assesses the causes of insurance deductions by using the Failure Mode Effects Analysis (FMEA) technique, and addresses the issues resulting in deductions by providing some interventions through the Pareto technique.

Design: The 10-step pattern of FMEA was implemented for assessing the main causes of insurance deduction in this study.

Setting: Data was collected from deduced amounts by three main/largest contracting party insurance organisations (e.g. the Social Security Insurance Organisation, Medical Services Insurance Organisation and Armed Forces Medical Services Insurance Organisation of Namazi Hospital, a large healthcare provider in the South of Iran, in 2014.

Findings: Sixty-five potential failure causes were identified, of which 26 were related to the anaesthesia unit, 23 were related to the surgery room unit and 16 were related to the hospitalisation unit. Deductions in the anaesthesia and hospitalisation units and the surgery room were reduced after intervention programs by 14.42%, 57.76%, and 51.52%, respectively.

Conclusions: Using the FMEA technique in a large healthcare provider in Iran resulted in identifying the main causes of insurance deductions and provided intervention programs in order to increase the efficiency and productivity of healthcare services.

Abbreviations: FMEA – Failure Mode Effects Analysis; RPN – Risk Priority Number.