Saudi Billing System: designing a standardized health insurance billing system in Saudi Arabia to support a national health system transformation

Abstract Background The Saudi health transformation program entails a comprehensive reform of all health system functions. One of the pillars of this reform is the health care financing transformation. The Council of Health Insurance (CHI) aims to bring more transparency and understanding of case-mix through the introduction of patient classification and data standardization. Until recently, the private health insurance sector was using a variety of in-house non-standardized billing codes that impeded transparency and a value-based health care (VBHC) financing model. This study enabled the introduction of standardized billing codes known as the Saudi Billing System (SBS). Methods We reviewed and assessed several patient classification and billing systems as part of the assessment phase, followed by data collection from eighty health care providers and the three largest health insurance companies, resulting in more than two million patient encounters for data analysis. A representative sample of 36,299 patient records were re-coded. Coding was undertaken using the Australian Classification of Health Interventions (ACHI) 10th Edition. Codes were assigned based on assessment by clinical coders using an established methodology and followed by an audit to confirm the assigned code or assign an alternative code where the coding could not be adequately completed by the initial coder. Results 75% of records were mapped to an existing ACHI code, leaving 25% being a partial match, an approximate match or other (1%, 22% and 2% respectively). As part of this process, the original ACHI codes were modified, and additional codes were added, ensuring full compatibility with billing practices. We named the new code set the Saudi Billing System (SBS). As a result of this work, we created an additional 1,774 codes, bringing the total SBS code set to 7,947 codes (30% increase from ACHI 10th Edition). Conclusions Patient classification and standardized billing systems are critical for transparency in providing health care and financing. Working within the existing national patient classification mandate and clinical coding standards required innovative ways to adapt these systems to a private health insurance market (specificity, familiarity, existing license with modification rights and ability to build fee schedule), to address the requirements of a reformed and more value-based insurance market. Current mandated patient classification systems are a good basis for adaptation to serve the needs of the overall health care transformation in the country and a building block towards more transparency and VBHC.