Insurance Deductions from Clinical Documentation Gaps: A Data Quality Perspective

Introduction: A significant portion of hospitals' financial resources is acquired through contracts with insurance companies. Insurance companies often reject claims or impose deductions on hospitals for various reasons, with poor medical record documentation being a major factor. This study aimed to identify the causes and extent of social security insurance deductions while evaluating which dimensions of data quality in medical records were compromised due to inadequate documentation. Method: This descriptive cross -sectional study was conducted in 2024 at Shahid Sadoughi Hospital in Yazd, divided into two phases. In the first phase, data collection was carried out using a checklist to extract services subject to deductions from 893 medical records covered by social security insurance. After grouping these services, the causes and extent of deductions were identified for each service group. In the second phase, documentation -related deductions were categorized according to data quality dimensions. Data analysis was performed using Excel and SPSS, employing descriptive statistics. Results: The highest deduction rate was observed in the emergency department at 24.1%, while the intensive care units had total deductions amounting to 2,980,112,989 rials. By service group, the greatest deductions were related to nursing care services (22.9%) and diagnostic tests (18%). Overall, documentation deficiencies represented the largest proportion of deductions at 45.3%. Within the data quality dimensions, incomplete documentation was the most frequent cause (62.4%). Conclusion: Documentation deficiencies, particularly regarding data completeness, significantly contribute to hospital deductions. Health information systems can help by offering a standardized format for electronic data recording and alerts for essential information. Additionally, it is recommended that physicians and other healthcare providers receive training on documentation practices that align with insurance payment guidelines. Furthermore, regular audits and feedback should be implemented to ensure continuous improvement and maintain the quality of medical record data.