gms | German Medical Science

Objectives/Interrogation: Previous international surveys report an increasing dissatisfaction among doctors with several aspects of practice, including income,workload and time consumed by administrative tasks being writing certificates and denied insurance claims among the most tedious. Purpose of the study was to assess the number of certificates for health insurances in a private practice, the prevalence and type of claim denials in hand surgery sent to the major health provider in Southern Switzerland.

Methods: An observational study was made, which retrospectively collected data from the claims and denial reports for "surgical"outpatients in hand surgery, including the number of certificates requested and completed for health insurances during the period 2013 to 2017. The denials were classified into "administrative"(AD) and "clinical"(CD). For each case the cause of denial, the time required to reply to insurances' requests, end result and time for bills to be payed were recorded. The certificates were divided into 3 categories: accidents, detailed reports for any reason and loss of income.

Results and Conclusions: The overall frequency of denials was 294, equivalent to 5,4% of the total number of invoices issued.

The frequency of AD was 82.6%, whereas that of CD was 19.4%. Any CD required an average time of 107.8 minutes of work compared to 6 minutes for AD. In 81% of cases the denial was not justified and led to a final payement of the original bill. The number of CD that required the surgeon's contribution for the invoice to be paid doubled from 2014 to 2016. The total number of certificates increased from 371 to 525 (+41%) being detailed reports the most noticeable.

Our data confirm previous surveys that health insurances and bureaucracy rob patients of doctor's time with a continous increasing trend over time. Compared to the U.S. literature the overall prevalence of denials in the studied sample was low but the limit of this study is that denials in private offices and for inpatients were not considered. Administrative denials were the most prevalent but the costs of surgeon's contribution to insurances' request should be considered and represented the only way for the reimbursement to happen. An easier coding system and a continuous education of all actors of the health system are mandatory to reduce the burden on surgeons and the billing offices of physician organizations.