Health insurance claims management systems: Potential factors affecting their decisions
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DOIhttp://dx.doi.org/10.21511/ins.16(2).2025.09
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Article InfoVolume 16 2025, Issue #2, pp. 112-123
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Type of the article: Research Article
Abstract
This study examines how patients’ health insurance claims were denied by different insurance providers at a Saudi Academic Medical Center (AMC), exploring the reasons for these rejections, their relationship to claim characteristics, and the factors that predict health insurance claim rejections. A descriptive study design was employed, involving a retrospective review of all insurance claims submitted by both inpatients and outpatients between January and December 2023 at a tertiary care AMC in Saudi Arabia. Following data screening using the UCAF 2.0 form, all denied insurance claims cases (n = 1,117) were subjected to qualitative analysis. The majority of rejected health insurance claims were submitted by female patients (56.9%) and outpatients (93.6%). Among the insurance companies studied, “Tawuniya” rejects the most insurance claims (n = 730). Variables such as age, gender, and insurance company were significantly associated with the reasons for denying claims (p < 0.05). Furthermore, variables such as age, cost, department type (inpatient/outpatient), and the month of claims are significant predictors of claim rejections (p < 0.05). However, gender, insurance companies, and clinical diagnosis were not significant (p > 0.05). The primary reasons for insurance claim denials in Saudi Arabia are missing medical data, system errors, and non-coverage of specific conditions. This study will help insurance companies and patients identify trends and reasons for claim rejections, enabling them to implement more effective preventive and corrective measures.
Acknowledgments
The authors expressed their gratitude to Imam Abdulrahman Bin Faisal University for granting permission [IRB-2024-03-188] to conduct this study.
- Keywords
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JEL Classification (Paper profile tab)I13, G22, I18
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References42
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Tables5
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Figures0
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- Table 1. Demographic profile
- Table 2. Chi-square statistic showing the association between insurance claim rejection reasons and the gender of patients
- Table 3. Chi-square statistic showing the association between insurance claim rejection reasons and the age group of patients
- Table A1. Chi-square statistic showing the association between insurance claim rejection reasons concerning different insurance companies
- Table B1. Linear regression showing those independent variables predicting insurance rejection claims
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- Al Amin, M., Shah, R., Tummala, H., & Ray, I. (2024). Utilizing blockchain and smart contracts for enhanced fraud prevention and minimization in health insurance through multi-signature claim processing. In 2024 International Conference on Emerging Trends in Networks and Computer Communications (ETNCC) (pp. 1-9). IEEE.
- Al Asmri, M., Almalki, M. J., Fitzgerald, G., & Clark, M. (2020). The public health care system and primary care services in Saudi Arabia: a system in transition. Eastern Mediterranean Health Journal, 26(4), 468-476.
- Alessa, A. O., & Alshagrawi, S. (2023). Evaluating the extent of health insurance knowledge and its associated factors among the insured population in Saudi Arabia. International Journal of Science and Research, 12(12), 1727-1733.
- Al-Hamad, B., Al-Dossary, N., Al-Muhaisen, H., Gollapalli, M., Rahman, A., & Ahmed, M. S. (2025). Minimum data set (MDS) in Saudi Arabia’s medical claims insurance. International Journal of Computer Science & Network Security, 25(2), 50-60.
- Al-Hanawi, M. K., & Qattan, A. M. (2019). An analysis of public-private partnerships and sustainable health care provision in the Kingdom of Saudi Arabia. Health Services Insights, 12, 1178632919859008.
- Aljarboa, S. S., & Miah, S. J. (2022, July 24). Discovering adoption barriers of clinical decision support systems in primary health care sector. arXiv preprint arXiv:2207.11713.
- Alkire, M. J. (2024, May 1). Unnecessary insurance claim denials compromise patient care and provider bottom lines. StatNews.
- Almalki, Z. S., Alahmari, A. K., Alshehri, A. M., Altowaijri, A., Alluhidan, M., Ahmed, N., Alabdulsalam, A. S., Alsaiari, K. H., Alrashidi, M. A., Alghusn, A. G., Alqahtani, A. S., Alzarea, A. I., Alanazi, M. A., & Alqahtani, A. M. (2022). Investigating households’ out-of-pocket healthcare expenditures based on number of chronic conditions in Riyadh, Saudi Arabia: a cross-sectional study using quantile regression approach. BMJ Open, 12(9), e066145.
- Al-Nozha, O. M. (2024). Key aspects of the Saudi healthcare system reform and the potential impact on the main stakeholders: A qualitative study. Journal of Taibah University Medical Sciences, 19(3), 598-610.
- Alonazi, W. B. (2017). Exploring shared risks through public-private partnerships in public health programs: a mixed method. BMC Public Health, 17, 571.
- Alonazi, W. B. (2020). Fraud and abuse in the Saudi healthcare system: A triangulation analysis. INQUIRY: The Journal of Health Care Organization, Provision, and Financing, 57, 0046958020954624.
- Alradhi, Z., & Alanazi, A. (2023). The road ahead and challenges of revenue cycle management in Saudi governmental hospitals. Healthcare, 11(20), 2716.
- Alshahrani, A. M. (2023). Predictors of patients’ satisfaction with primary health care services in the Kingdom of Saudi Arabia: A systematic review. Healthcare, 11(22), 2973.
- Alsuyayfi, S. S., Said, R. M., Ja’Afar, R., & Albada, A. (2023). A review of corporate governance in the Saudi Arabian insurance sector. Journal of Risk Management in Financial Institutions, 16(3), 293-303.
- Alzahrani, A. A., Pavlova, M., Alsubahi, N., Ahmad, A., & Groot, W. (2025). Impact of the cooperative health insurance system in Saudi Arabia on universal health coverage – A systematic literature review. Healthcare, 13(1), 60.
- Alzghaibi, H. A. (2023). An examination of large-scale electronic health records implementation in primary healthcare centers in Saudi Arabia: a qualitative study. Frontiers in Public Health, 11, 1121327.
- Attia, N., Moussa, K., Altwaim, A., Al-Agha, A. E., Amir, A. A., & Almuhareb, A. (2024). Tackling access and payer barriers for growth hormone therapy in Saudi Arabia: a consensus statement for the Saudi Working Group for Pediatric Endocrinology. Journal of Pediatric Endocrinology and Metabolism, 37(5), 387-399.
- Council of Health Insurance. (2021, March 11). NPHIES activation.
- Council of Health Insurance. (2023). Annual report 2023.
- Davis, E. (2024, October 6). Reasons for health insurance claim denials and what you should do. Very Well Health.
- Derouez, F., & Bin Shary, N. F. (2025). The impact of medical insurance penetration and macroeconomic factors on healthcare expenditure and quality outcomes in Saudi Arabia: An ARDL analysis of economic sustainability. Sustainability, 17(12), 5604.
- Glance Care. (2022, September 10). 9 reasons health claims are being rejected or denied by insurance in Saudi Arabia.
- Glenwood Systems. (2025, July 5). 13 reasons why your claim was denied.
- HDFC ERGO Team. (2024, September 10). Reasons for your individual health insurance plan to get rejected.
- Hoagland, A., Yu, O., & Horný, M. (2024). Social determinants of health and insurance claim denials for preventive care. JAMA Network Open, 7(9), e2433316.
- Insurance Authority, Saudi Arabia. (2023). The Saudi insurance sector report, 2023.
- Kim, B. H., Sridharan, S., Atwal, A., & Ganapathi, V. (2020, July 13). Deep claim: Payer response prediction from claims data with deep learning. arXiv preprint arXiv:2007.06229.
- Kusumoto, F., Ross, J., Wright, D., Chazal, R. A., & Anderson, R. E. (2024). Analysis of closed claims among all medical specialties: Importance of communication and other non-clinical contributing factors. Risk Management and Healthcare Policy, 17, 411-422.
- LaPointe, J. (2025, January 9). Breaking down claim denial rates by healthcare payer. TechTarget.
- Maryland Local Health Department. (2015, July 5). 10 common medical billing mistakes that cause claim denials. Maryland Local Health Department-Billing Manual.
- Matson, A. P., Earp, B. E., Benavent, K. A., Geresy, K. M., Collins, J. E., & Blazar, P. E. (2020). Predictors of insurance claim rejection in hand and upper extremity surgery. Journal of the American Academy of Orthopaedic Surgeons, 28(15), e662-e669.
- Nabrawi, E., & Alanazi, A. (2023). Fraud detection in healthcare insurance claims using machine learning. Risks, 11(9), 160.
- Osman, M. A., & Ali Ismail, E. A. (2018). A quantitative model to identify key determinants for health insurance claims in the Kingdom of Saudi Arabia. Journal of King Saud University, 27(2), 23-35.
- Park, Y. T., Yoon, J. S., Speedie, S. M., Yoon, H., & Lee, J. (2012). Health insurance claim review using information technologies. Healthcare Informatics Research, 18(3), 215-224.
- Reka, H., Mazevska, D., Pearse, J., Al Maghrabi, A., Young, S. E., & Al Ghamdi, S. (2023, November 16). Saudi billing system: designing a standardized health insurance billing system in Saudi Arabia to support a national health system transformation. Research Square.
- Saudi Gazette. (2024, January 4). Saudi insurance sector targets 25 million beneficiaries by 2030.
- Shahbar, A., Katlan, D. A., Almutairy, R. F., & Alnoamy, Y. (2024). Optimizing medication therapy in elderly patients: Therapeutic management challenges and strategies. In Alharthi, A. H. (Ed.), Difficulties and challenges in geriatric health management (pp. 45-82). IGI Global Scientific Publishing.
- Tallapaneni, J., Harrington, M., Troiani, Z., Venturino, L., & Rosenbaum, A. (2023, August 21). The impact of insurance status on patient placement into inpatient and outpatient orthopedic surgical centers in the United States. Research Square.
- The Economic Times Wealth. (2025, July 5). 10 reasons why your health insurance claim can get rejected and how to avoid it.
- Tolentino, J. C., Stoltzfus, J., Harris, R., Mazza, A., Foltz, D., Deringer, P., Sakran, J. V., Menak, R., Mira, A.-E. A., Nguyen, M. C., Moffatt-Bruce, S. D., Huerta, T. R., Papadimos, T. J., & Stawicki, S. P. (2017). Comorbidity-polypharmacy score predicts readmissions and in-hospital mortality: A six-hospital health network experience. Journal of Basic and Clinical Pharmacy, 8(3), 98-103.
- Ubhar Capital. (2023, November 15). Saudi Insurance Sector.
- UCAF. 2.0. (2025). UCAF 2.0 form of Certification Commission for Healthcare Interpreters (CCHI).


