Health insurance claims management systems: Potential factors affecting their decisions

Type of the article: Research ArticleAbstractThis study examines how patients’ health insurance claims were denied by different insurance providers at a Saudi Academic Medical Center (AMC), exploring the reasons for these rejections, their relationship to claim characteristics, and the factors that predict health insurance claim rejections. A descriptive study design was employed, involving a retrospective review of all insurance claims submitted by both inpatients and outpatients between January and December 2023 at a tertiary care AMC in Saudi Arabia. Following data screening using the UCAF 2.0 form, all denied insurance claims cases (n = 1,117) were subjected to qualitative analysis. The majority of rejected health insurance claims were submitted by female patients (56.9%) and outpatients (93.6%). Among the insurance companies studied, “Tawuniya” rejects the most insurance claims (n = 730). Variables such as age, gender, and insurance company were significantly associated with the reasons for denying claims (p < 0.05). Furthermore, variables such as age, cost, department type (inpatient/outpatient), and the month of claims are significant predictors of claim rejections (p < 0.05). However, gender, insurance companies, and clinical diagnosis were not significant (p > 0.05). The primary reasons for insurance claim denials in Saudi Arabia are missing medical data, system errors, and non-coverage of specific conditions. This study will help insurance companies and patients identify trends and reasons for claim rejections, enabling them to implement more effective preventive and corrective measures.AcknowledgmentsThe authors expressed their gratitude to Imam Abdulrahman Bin Faisal University for granting permission [IRB-2024-03-188] to conduct this study.