Dissertation for M.A.
Insurance Management Orientation
Abstract
Today, health and treatment centers, especially hospitals, have a major part of the resources allocated to the health and treatment season. Therefore, controlling these resources in order to use them correctly and efficiently and prevent them from being wasted is one of the important tasks of management. Hospitals are one of the most important centers providing medical services. Therefore, it is very important to examine how to use the facilities and resources available in this sector and their effectiveness. The present research has been conducted with the aim of knowing the causes of insurance deductions (medical service insurance) in the files of patients hospitalized in Ardabil public hospitals. This research is of a descriptive type and a branch of field studies. The statistical population of the research consists of the missing files of patients hospitalized in four government hospitals of Ardabil city (Imam Khomeini, Alavi, Fatemi and Bu Ali), which includes 11889 files. The sample size was determined as 400 cases in each of the four hospitals. Data collection was done using a standard checklist. Data analysis was done by calculating variance analysis and Duncan's test and using SPSS software. The findings showed that there is a significant difference between the causes of deductions in hospitals. The findings also showed that there were the most deductions in the medicine, radiology and laboratory departments of hospitals.
Key words: insurance deductions, hospital, Ardabil
Introduction
Today, maintaining and improving the level of health and well-being of the society is considered one of the important infrastructure, development and progress of the society and the desire for social, political and economic development in the sense of improving the standard of living is one of the priorities of every society and amal. Every nation is considered and is an integral part of the trends of human evolution. In today's era, when human health is exposed to various injuries and accidents than ever before, the important role of hospitals and medical centers in restoring the health of members of the society as scientific and specialized centers in the process of medical care is becoming more visible. Considering this feature, the hospital management has a social responsibility to provide health services needed in the society, at an acceptable level of quality and at the lowest possible price and cost. Between 50 and 80 percent of public sector health benefits in developing countries are consumed by hospitals. With a better and more accurate understanding of the costs related to various activities, managers can moderate the efficiency of hospital departments and departments as well as the hospital itself as a whole. Also, the ways related to costs can help policymakers in deciding about the best medical care provided in hospitals, as well as the balance and conflict between prevention services and primary and secondary medical services (Mohammadi et al., 2013). Because this problem will lower the quality of services and eventually the patients will be dissatisfied with the hospital (Khormi et al., 2013).
With the increase in health and treatment sector costs, health sector policy makers focus on the most expensive service sector, which is hospital services. Hospital services account for almost half of the total costs of the health sector. Therefore, it seems necessary to improve the efficiency of these services by reducing costs and using the potential capacities of health and treatment institutions (Fakari et al., 2018). With a more reliable and accurate understanding of the costs related to various activities, managers can moderate the efficiency of hospital departments and departments as well as the hospital itself as a whole. Also, cost-related data can help policymakers in deciding on the best care provided in hospitals and the balance and conflict between prevention services and primary and secondary treatment services (Tavakli et al., 2015).
Since insuring people is on the agenda of the government, the number of insured people is increasing day by day, and the increase in income also depends on the institutions of the contracting parties. However, due to various reasons, including the inclusion of additional and unnecessary services by government hospitals that are not accepted by the insurer, deductions are applied in the reimbursement of the contract party's hospital bills, and in this way, a part of the income is wasted through deductions, which is the cause of the dissatisfaction of the contracting party hospitals, and the long delay in the reimbursement of their claims aggravates the dissatisfaction. Therefore, the issue of the amount and cause of deductions is considered important: in a way that it both informs the employees of the medical centers, pharmacies, and related management, and also increases the income of the centers, and also causes a mutual trust between the parties to the contract.
Documenting the cases helps to determine the amount of reimbursement that the hospital receives from the insurance organizations. The patient's file at the time of discharge should fully document the services provided to the patient and show that these services were necessary for the patient and suitable for his condition. Defects in these documents directly affect reimbursement (Mohammadi et al., 2013).
The purpose of this research is also to find the problems that the parties in this relationship have with each other because controlling and solving problems between hospitals and insurance organizations and the existence of an efficient and effective relationship can be useful for the hospital because these problems can cause financial losses for the hospital and also for the insurance organizations to defend the rights of the insured and prevent financial losses and It is useful to have efficiency and productivity in its resources and to help control the costs of the health system, and after recognizing all kinds of problems, it is necessary to provide a practical model to solve them. Considering the importance of the discussion of deductions for the university and all executive centers and the lack of similar research in the province, the researcher has decided to conduct this study. Also, the causes of specific deductions and effective solutions are presented, which can be taken by reflecting it to the university officials and informing them of the current situation, and useful measures can be taken in order to eliminate them.
Is there a significant difference between the causes of insurance deductions (medical services insurance) in the case of patients hospitalized in the state hospitals of Ardabil city? They are operational in the healthcare system. Therefore, it is necessary to run hospitals more economically to avoid wasting resources. One of the topics that can be discussed in the introduction of the economic administration of hospitals, which has always been the focus of attention and diligence of hospital managers, is mastering and controlling the financial situation of the hospital, providing the required financial resources and increasing the efficiency in the revenue department of hospitals (Khormi et al., 2013). Due to their extensive function, hospitals take up a major part of the resources allocated to the health and treatment sector (Askari et al., 2019). Therefore, considering the growing trend of medical expenses and the limitation of financial resources, the need to pay attention to the issue of controlling the costs of hospitals, which have taken up a major part of the resources allocated to the health and treatment sector, is inevitable (Safdari et al., 2019).
Complex Being in the field of healthcare services, the high costs and the growth of prices in it, the ever-increasing demands for the enjoyment of health and health, the limitation of financial and human resources, the high productivity and the use of cost control methods have become more vital in this field (Askari et al., 2019). According to this plan, all the expenses of hospitals and medical training centers, except for the salaries of the official and contracted personnel, are covered from their own sources of income. This indicates the need to pay attention to the financial management of hospitals. A review of the reduction of government support for hospitals and medical training centers in the past years shows the reliance of these units on their own income. The management of these units have no choice but to take measures to increase income and reduce costs.