Hospital Practices and Research

Hospital Performance in Reducing Insurance Deductions in the Health Sector

Document Type : Original Article

Authors

Monika Motaghi 1
Lida Gholizade 2

1 Department of Health, Shahrekord Branch, ShK.C., Islamic Azad University, Shahrekord, Iran

2 Department of Nursing & Midwifery, Gac.C., Islamic Azad University, Gachsaran, Iran

https://doi.org/10.30491/hpr.2025.508465.1477
Abstract
Background: Today, providing household health expenses for the health system is an important challenge. The increase in health service costs has created some problems. In this regard, the insurance seems to play a key role in such expenses for the household. One of the major problems between healthcare centers and insurance organizations is about the reimbursement of services provided to patients by the insurers according to the contract. Substantial amounts of these expenses, categorized as deductions, are not reimbursed to the healthcare centers by the insurance organizations.
Objectives: The purpose of this study was to investigate the effective measures in reducing insurance financial deductions with an emphasis on the role of insurance.
Methods: The current research was descriptive-analytical and cross-sectional, which was conducted in Shahid Rajaei Hospital of Gachsaran. For this purpose, 170 patients (families) were selected as research samples, and finally 165 patients (families) were included in the study. The research population consisted of 400 employees of Shahid Rajaei Hospital in Gachsaran, and a simple random sampling method was employed to select 196 participants, according to Cochran's formula. A researcher-developed questionnaire with 21 questions was used for data collection. The formal and content validity of the questionnaire was confirmed, and its reliability was verified using Cronbach's alpha. The collected data were analyzed using parametric tests by SPSS software.
Results: The research data indicated that uncompromised elements such as not distorting the date and prescription, having the stamp and signature on insurance prescriptions, transparent and digitally typed medical orders, proper completion of medical procedures descriptions by physicians, accurate and precise registration of equipment, drugs, and supplies, proper registration and documentation of daily requests, and request for basic care instructions in medical and nursing orders, have an impact on reducing insurance financial deductions at Shahid Rajaei Hospital in Gachsaran, across the inpatient, clinical, and administrative departments.
Conclusion: Based on the obtained results, by implementing effective and transparent measures, identifying and eliminating factors contributing to the increase in insurance deductions, it is possible to reduce the disputes between hospitals and insurance organizations. The findings show a significant relationship between health insurance coverage and use of preventive care services, adverse health outcomes, reduced performance, preventable health problems, severe disease at the time of diagnosis, and premature mortality.

Keywords

Insurance
Financing
Hospital
  1. Maleki M, Bolghadr S, Aghaeihashjin A. Determining the amount and causes of insurance deficits in selected teaching and non-teaching hospitals affiliated to Iran University of Medical Sciences. J Health Adm. 2021;23(4):80-91. doi:10.29252/jha.23.4.80
  2. Zhu Y, Zhao Y, Dou L, Guo R, Gu X, Gao R, et al. The hospital management practices in Chinese county hospitals and its association with quality of care, efficiency and finance. BMC Health Serv Res. 2021;21(1):449. doi:10.1186/s12913-021-06472-7
  3. Motaghi S, Amini Milani M, Keshavarz M, Zabeti M, Fathizadeh A. Investigating the factors affecting catastrophic costs with emphasis on the role of insurance. Iran J Health Insur. 2022;5(1):52-9.
  4. Ellis RP, Manning WG. Optimal health insurance for prevention and treatment. J Health Econ. 2007;26(6): 1128-50. doi:10.1016/j.jhealeco.2007.09.002
  5. Bittoni MA, Wexler R, Spees CK, Clinton SK, Taylor CA. Lack of private health insurance is associated with higher mortality from cancer and other chronic diseases, poor diet quality, and inflammatory biomarkers in the United States. Prev Med. 2015;81: 420-6. doi:10.1016/j.ypmed.2015.09.016
  6. Kavousi M, Sefati F. Forecasting hospital income based on the causes of insurance deductions. The second national conference on accounting, management, and economics with a sustainable employment approach and its role in industry growth. Islamic Azad University, Malair Branch; 2017. Available from: https://civilica.com/doc/844606
  7. Esfinjani A, Nasrabadi H, Bakhtiar A. Developing a digital transformation model in the insurance industry. 25th National Conference on Insurance and Development, Tehran, 2019. Available from: https://civilica.com/doc/825886
  8. Baghban B. Investigating discrepancies and causes of deductions applied by the Health Insurance Organization to bills sent from teaching hospitals in Mashhad. Management, Entrepreneurship and Accounting Conference, Kish, Iran. 2019. Available from: https://civilica.com/doc/818095
  9. Kolstad JT, Kowalski AE. The impact of health care reform on hospital and preventive care: evidence from Massachusetts. J Public Econ. 2012;96(11-12):909-29. doi:10.1016/j.jpubeco.2012.07.003
  10. Hoffman C, Paradise J. Health insurance and access to health care in the United States. Ann N Y Acad Sci. 2008;1136(1):149-60. doi:10.1196/annals.1425.007
  11. Jafari M, Parvin k, Sadeghi M. Legal principles and economic systems governing Iran health insurance. Iran J Health Insur. 2023;6(3):159-72.
  12. Karimi S, Sari A, Fazaeli AA, Fazaeli AA. The study of indicators of equity in health care financing and their applications in Iran. Iran J Health Insur. 2023;6(2):77-90.
  13. Garcia-Cornejo B, Perez-Mendez JA. Assessing the effect of standardized cost systems on financial performance. A difference-in-differences approach for hospitals according to their technological level. Health Policy. 2018;122(4):396-403. doi:10.1016/j.healthpol.2018.01.013
  14. Rahimi Diali H, Mansouri F. Examining the effects of failure to comply with the obligations of the parties to the insurance contract regarding the provision of information and financial payments. International Conference on Religious Studies, Islamic Sciences, Jurisprudence and Law in Iran and the World, Karaj, Iran. 2019. Available from: https://civilica.com/doc/ 819357
  15. Chuma J, Maina T. Catastrophic health care spending and impoverishment in Kenya. BMC Health Serv Res. 2012;12(1):413. doi:10.1186/1472-6963-12-413
  16. Makhsosi BR, Amiri H, Evani N, Kazazi S. Evaluation of the causes of prescription deductibles in a teaching hospital in Kermanshah. Payesh. 2021;20(4):415-25. doi:10.52547/payesh.20.4.415
  17. Hasani Torki M, Hashemi Nazari SR. Investigating the amount and causes of deductions applied by insurance organizations to invoices sent by Khatam Al-Anbiya Hospital and Miyaneh County. The 2nd International Conference and the 4th National Conference on Management Studies and Humanities in Iran, 2018. Available from: https://civilica.com/doc/ 713998
  18. Lee TS, Kilbreath SL, Sullivan G, Refshauge KM, Beith JM. The development of an arm activity survey for breast cancer survivors using the Protection Motivation Theory. BMC Cancer. 2007;7(1):75. doi:10.1186/1471-2407-7-75
  19. Polit DF, Beck CT. Nursing research-principle and methods Lippincott Williams & Wilkins. Philadelphia. 2004.
  20. Lawshe CH. A quantitative approach to content validity. Pers Psychol. 1975;28(4):563-75.
  21. Sarvestani N, Mohammadi KP, Kavoosi Z, Yousefi A. The amount and causes insurance deductions of Shohada-e Sarvestan hospital and ways to reduce it by using the techniques of problem solving, 2012. J Manage Med Inform Sci. 2015;2(2):122-32.
  22. Muriana C, Piazza T, Vizzini G. An expert system for financial performance assessment of health care structures based on fuzzy sets and KPIs. Knowl-Based Syst. 2016;97:1-10. doi:10.1016/j.knosys.2016.01.0 26
  23. Mosaniazare SA, Asefzadeh S, Sepordeh Y, Mirtamizdost M. Comparison of the income and expenses of Shahid Ansari Rudsar Hospital in 2012. International Management Conference, Tehran. 2015. Available from: https://civilica.com/doc/343577
  24. Shahrami A, Hatamabadi H, Maher A, Zandiyeh F. Comparative study of the situation of insurance deductions in the hospital before and after the implementation of the productivity promotion system. Iran J Emerg Med. 2020;7(1):e35. doi:10.22037/ijem.v7i1.31096
  25. Agrizzi D, Agyemang G, Jaafaripooyan E. Conforming to accreditation in Iranian hospitals. Account Forum. 2016;40(2):106-124. doi:10.1016/j.accfor.2016.02.002
  26. Wang T, Wang Y, McLeod A. Do health information technology investments impact hospital financial performance and productivity?. Int J Account Inf Syst. 2018;28:1-13. doi:10.1016/j.accinf.2017.12.002
  27. Hosseini-Shokouh SM, Matin HM, Yaghoubi M, Sepandi M, Ameryoun A, Hosseini-Shokouh SJ. Amount and causes of insurance deductions for the armed forces medical services organization in a military hospital in Tehran, Iran. J Mil Med. 2018; 20(4):402-11.
  28. Lopez-Valeiras E, Gomez-Conde J, Lunkes RJ. Employee reactions to the use of management control systems in hospitals: Motivation vs. threat. Gaceta sanitaria. 2018;32:129-34. doi:10.1016/j.gaceta.2016. 12.003
  29. Schelling G, Heesen P, Tautermann B, Wepf M, Di Federico B, Frei A, et al. Impact of Institutional Practices and Surgical Complexity on Sarcoma Surgery Costs: Driving Efficiency in Value-Based Healthcare. Cancers. 2024;16(12):2209. doi:10.3390/cancers16122209
  30. Marathe S, Ingle P, Yakkundi D, Scott K. What stops private hospitals from engaging with publicly funded health insurance schemes? A mixed-methods study on PMJAY/MJPJAY in Maharashtra, India. BMC Health Serv Res. 2025;25(1):389. doi:10.1186/s12913-025-12450-0

Home

Guide for Authors

Submit Manuscript

Reviewers

Contact Us