This was edited from the original idea “editing a claim”. It was analysed that a doctor cannot change a claim using "edit". A new claim request must always be created to correct errors.
Presumably, this is supposed to contribute to less fraud & abuse, but it proves to be inappropriate in practice.
It is suggested that ONE edit should be possible after the claim has been "rejected".
The workflow could be made very practical and include a "state the reason for edit" (this can be selected via dropdown).
It should be visible in the system that a claim is an "original" claim or a "revised" claimdeemed that editing a claim should not be allowed for fraud control purposes, rather it is more interesting to focus on the claims resubmission process. Indeed, it should be more clear exactly what the “standard” process should be if a submitted claim is incorrect and needs to be altered. This is particularly interesting for new implementations and programs that in the process of setting up a health insurance scheme, such as in Niger and Mauritania, where the claims management procedures are not necessarily in place yet. If the openIMIS Community could provide a standardized process on claim resubmission, scheme administrators would then already be guided on best practice when using openIMIS. |