Healthcare-Rejection Re-submission Sample -To be integrated with HIS Sys

Mopn

Dr. Noor Mohammed Khan General Hospital

Re-Submission of Medical Rejections to Bupa

Claim Processing Summary

Initial Statement

Provider Billed 2,652,173.09 295,873.00

Discount Presented 296,685.39 28,160.00

Deductible 264,064.55 25,660.00

Net Billed 2,091,423.15 242,053.00

Deduction TOTAL Jan-13

Invalid Membership 4,637.28 -

Difference in Computation - -

Claims not Received 555.00 -

Invalid Service Code 24,824.32 4,020.00

Late Submission 232.55 -

Appropriateness of Care 209,882.64 26,946.14

Technical /Contractual 101,233.93 20,030.42

Policy Compliance 69,658.70 5,958.89

Pre-athorization 18,880.18 1,668.30

Unwarranted Variation 9,680.00 7,600.00

Discount difference 155,336.84 23,362.63

Deductible Difference - -

Pending 5,600.00 -

Deduction 600,521.44 89,586.38

Summary

The above data have been extracted from Bupa claim processing department, consisting 9 months from

January -2013 to September - 2013 to further work

forthcoming dealings. As you know we are facing shortage of staff since inception and that is the main

reason we didn’t give much importance to credit & insurance department from the beginning otherwise

such rejections cases can be handled

expertise from concern Doctor (s) . If we review all above cases

that there are small steps are omitted

after receiving rejections with retionale justifications.

meeting with associated partners are

business knowledge in the relevant fields.

I believe that current reports are

insurance department for increasing business profitability by peer thinking

Policy Compliance

11%Pre-

athorization

3%

Unwarranted

2%

Discount diff

26%

Claimed Rejected by Bupa

By: Ghulam Abbas, Group FM

Submission of Medical Rejections to Bupa

For the period from January - 2013 to September-2013

295,456.60 254,015.26 301,210.43 287,407.56 285,751.52

33,089.09 34,217.48 34,014.76 30,897.64 32,432.33

28,219.17 31,544.03 30,802.32 28,656.16 27,702.15

234,148.34 188,253.75 236,393.35 227,853.76 225,617.04

Feb-13 Mar-13 Apr-13 May-13 Jun-13

117.15 - 2,305.40 387.17 622.50

- - - - -

- - 555.00 - -

3,848.32 632.00 264.00 3,312.00 116.00

- - - - -

33,555.17 19,065.32 22,268.93 12,993.71 19,320.66

9,923.66 8,836.82 11,570.66 8,964.25 13,254.74

5,990.94 12,513.18 5,659.17 8,364.59 9,401.43

852.09 2,561.43 2,678.82 2,941.71 1,684.39

- - - - -

18,503.03 8,859.86 17,811.66 17,813.04 16,017.23

- - - - -

- - 3,800.00 224.00 264.00

72,790.36 52,468.61 66,913.64 55,000.47 60,680.95


2013 to further workout and decrease the medical rejections for

As you know we are facing shortage of staff since inception and that is the main


ons cases can be handled easily with little help from the medical staff or by provision of

. If we review all above cases one by one, we would be acquainted with

omitted which requires to furnish them either before dispatching of claims or

after receiving rejections with retionale justifications. Confronting as well as proper feedback

are also a big space between us to save our income

business knowledge in the relevant fields.

current reports are being forced to DNMK management to pay more heed to

for increasing business profitability by peer thinking.

Invalid

Member

1%

not Received

0%

Invalid S-Code

4%

L-Submission

0%

Appro- of Care

35%

Technical

/Contractual

17%

Pending

1%


For the period from January - 2013 to September-2013

282317.04 314,775.00 335,366.68

29661.95 35,652.10 38,560.04

26713.26 31,786.59 32,980.87

225,941.83 247,336.31 263,825.77

Jul-13 Aug-13 Sep-13

- 846.00 359.06

- - -

- - -

11,164.00 312.00 1,156.00

- 232.55 -

18,505.12 24,335.26 32,892.33

6,878.66 10,249.12 11,525.60

3,263.50 7,773.45 10,733.55

1,518.40 2,472.28 2,502.76

- - 2,080.00

17,731.80 16,830.59 18,407.00

- -

1,192.00 120.00 -

60,253.48 63,171.25 79,656.30


and decrease the medical rejections for

As you know we are facing shortage of staff since inception and that is the main


or by provision of

be acquainted with

them either before dispatching of claims or

as well as proper feedback from the

between us to save our income due to lack of

management to pay more heed to

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Rejection Category: F

Rejection Reasons: Unwarranted Variation

Total Rejected Amount: SAR 9680.00

Reporting Period: From January – September -2013

Explanation Note

The said cases have been investigated with technical team while treated physician also called for briefing.

All above cases have been done in our hospital along with prior approval from Bupa Arabia. We believe

there are enormous communication and coordination gap between bupa claim department and DNMK

medical team otherewise these cases can easily be identified on demand if Bupa arabia asked for

additional evidence before writing “ services not done”. Let me epigrammatic first the whole proceudres

since incpetion. In inpatients services, we are not forwarding all supportind documents in package deal

services while it can also be provided on demand. In observation cases, we provide all supporting

documents including test results for your review. This is normal routine and since inception all insurance

companies are respecting these practices as original records goes to patient file for future references /

MOH requirements.

Kindly look into the matter for a second time while we are enclosing necessary supporting documents for

above mentioned case. If you need any other assistance we are ready to brief you. In future, we can

enclose all supportind documents with package deal of such cases if bup arabia requires.

Enclosed:

• Approvals

• Summary Sheet

• Discharge Sheet

• X-ray Report

• Lab Result Reports

• Affidavit

• Treatment Checklist

• Anaesthesia Record

• Surgery Report

• Post Anesthesia Record

It is, therefore, request to reconsider these cases for your kind approval please. Please consider all the

rejections in term of category “F-service not done” with similar sound logical grounds.

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Rejection Category: E-Pending

Rejection Reasons: Missing documents

Total Rejected Amount: SAR 3800


DNMK Remarks

As required by the bupa, missing documents have been enclosed herewith to review the case. Please find

below the details of missing documents:

Patient Name: Sana Abdullah al Khaldi

• Discharge sheet

• Summary Sheet

• Agreement form

• Theatre checklist


• Post operative anesthesia record

• Portograph

• CTG report

Rejection Category: E-Pending

Rejection Reasons: Payable amount pending, please send

Total Rejected Amount: SAR 1800


DNMK Remarks

Needful done by treated doctor. Following documents are being enclosed for your final review

please.

• Approval of this case

• UCAF

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Rejection Reasons: Invalid Service Code



Explanation Note

As we discussed earlier and also part of my several emails in which I clearly raised some points that bupa

arabia havn’t updated its system for additional services those added after arrival of new

equipments/specialities. For this purpose our customer support department also forwarding an official

notification and obtain necessary prior approval once related services ocurred in our hospital. You can

reinvestigate carefully all our claims wherein we have enclosed approval from Bupa with each and every

claimed services whereas required mandatory approval from bupa arabia. If approval not taken you may

reject case but not in term of invalid service or code etc.

We hope all such cases recosider with grounds reality and bupa arabia would also update pricelist

(additional document enclosed) to avoid any rejection in term of invalid service code.

Rejection Reasons: Late Submission

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Rejection Reasons: Unwarranted Variation



Explanation Note

The said cases have been investigated with technical team while treated physician also called for briefing.

All above cases have been done in our hospital along with prior approval from Bupa Arabia. We believe

there are enormous communication and coordination gap between bupa claim department and DNMK

medical team otherewise these cases can easily be identified on demand if Bupa arabia asked for

additional evidence before writing “ services not done”. Let me epigrammatic first the whole proceudres

since incpetion. In inpatients services, we are not forwarding all supportind documents in package deal

services while it can also be provided on demand. In observation cases, we provide all supporting

documents including test results for your review. This is normal routine and since inception all insurance

companies are respecting these practices as original records goes to patient file for future references /

MOH requirements.

Kindly look into the matter for a second time while we are enclosing necessary supporting documents for

above mentioned case. If you need any other assistance we are ready to brief you. In future, we can

enclose all supportind documents with package deal of such cases if bup arabia requires.

Enclosed:

• Approvals

• Summary Sheet

• Discharge Sheet

• X-ray Report

• Lab Result Reports

• Affidavit

• Treatment Checklist


• Surgery Report

• Post Anesthesia Record

It is, therefore, request to reconsider these cases for your kind approval please. Please consider all the

rejections in term of category “F-service not done” with similar sound logical grounds.

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Rejection Reasons: B.6-another Valid Service code is applicable to the service done.

Total Rejected Amount: listed SAR 9600.00 (actual rejection 15600)


Explanation Note

The above mentioned case have been discussed with concerned doctor and have decleared that the code of

ORT-27009 is “DCS-dynamic compression plate & screw is different application and procedures for the

rgular plate & screw” which had also been forwarded for approval as well as patient treated according to

the related services in term of package deal, furthermore coding which have been listed by bupa is leading

towards “FRACTURE FEMUR (PLATE & SCREWS” is different type of operation, not directly realted

to that case.

There are two foremost mistake in the bupa rejections:

1. Bupa is being charged discount on package deal services which is not agreed in the contractual

list.

2. Bupa has listed least price of operation in above case and then charged discount on it, in result of

that operation price reduced up to 52%.

Kindly review contract details and let us know if you have any observation for that, we would appreciate

if claim checking representative directly coordinate with our orthopedic team for further clearance of

above case or any case creates doubt or more explaination before fully rejection.

Enclosed:

• Copy of necessary documents to be reviewed for your persual

• Copy of claimed summary to know accurate prices

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Rejection Reasons: C.1 Your facility was not assigned for the member/class on the date

of service



Explanation Note

We have check all cases, one by one reviewed and found that all patients have been reffered valid

date/approval by bupa from other clinics, with permission of bupa Arabia, clearly marked that “Service is

reffered to Dr. Noor Mohammed Khan General Hospita”. Kindly see enclosed documents. We are

enclosing all rejected cases for your review and put into payment queue.

We also noticed that such rejection is the carelessness of the claimed checking officer as we have clear

policy for all inusrance companies to accept the patient with proper supporting documents or refferal

letter in which clearly mentioned provider name.

We are expecting that bupa arabia have excellent system to be verified each claim through online

approval/tracking number, either this patient was eligible to garner treatment from the specific date in

claiming proivder list. If yes, then rejections is just reducing the claimed amount to pay less amount to the

provider.

Enclosed:

• Copy of all refferal letters, approved by Bupa arabia

Healthcare-Rejection Re-submission Sample -To be integrated with HIS Sys

Health & Medicine

Transcript of Healthcare-Rejection Re-submission Sample -To be integrated with HIS Sys