An Analysis of Claims Adjustment Processes in Georgia’s Health Insurance Sector: Qualitative Study

Abstract

Objective: Efficient management of insurance claims is essential for the financial stability of the healthcare system. This study aims to examine the challenges and systemic issues that affect health insurance claims management and to identify areas for operational improvement.

Methodology: A qualitative research design was employed, supported by quantitative claims data to ensure methodological triangulation. Twelve in-depth semi-structured interviews were conducted with managers and administrative staff from a leading Georgian private insurance company and affiliated healthcare providers. Interview transcripts were thematically analyzed through an inductive–deductive coding process, informed by transaction cost and principal–agent theories. Quantitative data from the insurer’s 2022–2024 internal claims database were analyzed using descriptive statistics to identify trends in submission, correction, and revision. Triangulation between qualitative themes and quantitative indicators served as a validation strategy.

Results: The qualitative analysis revealed recurring themes related to administrative inefficiency, communication barriers, and contractual non-compliance. Key themes included: (1) incomplete or inconsistent documentation leading to claim adjustments; (2) weak coordination and information sharing between insurers and providers; and (3) tolerance of deadline and pricing violations for high-demand clinics to maintain service continuity. Quantitative results showed that approximately 2% of all claims required correction or revision, primarily due to documentation and referral issues. Hospitals accounted for the majority of claims and adjustments.

Conclusion: The study highlights significant operational inefficiencies and communication gaps in Georgia’s health insurance claims process. The lack of standardized documentation protocols, reliance on manual systems, and frequent breaches of contract terms all contribute to delays, disputes, and financial strain for both insurers and providers. To improve claims management in Georgia, the process should be digitized and documentation standardized to reduce errors. Staff training must be strengthened, and regulatory oversight enhanced through performance-based contracts.