New obligations of private healthcare institutions and emergency care

In a pivotal step aimed at enhancing the efficiency of the healthcare sector in Saudi Arabia, the National Health Insurance Council has adopted a new regulatory mechanism governing the purchase of healthcare services from the private sector. This step establishes a comprehensive procedural framework to regulate interactions between the National Health Insurance Center and all private healthcare institutions , ensuring the rights of beneficiaries and improving the quality of services provided.

The context of health transformation and Vision 2030

These regulatory decisions are fully aligned with the objectives of the Health Sector Transformation Program, one of the programs under the Kingdom's Vision 2030, which aims to restructure the health sector into a comprehensive, efficient, and integrated healthcare system. This mechanism is part of efforts to enhance the role of the private sector as a strategic partner in service delivery, while ensuring robust governance that guarantees transparency and equitable distribution of healthcare services, and transitioning from a pay-for-service model to a pay-for-value and quality model.

Cancellation of prior approval for emergency cases

Perhaps the most significant aspect of the decision is the firm assertion that the provision of emergency healthcare will not be contingent upon obtaining any prior approval. This decision carries profound humanitarian and health implications, placing the patient's life above any administrative or financial considerations. The council has held healthcare providers fully responsible for final medical decisions, ensuring a rapid response to critical cases and saving lives without bureaucratic delays.

The 16 most important commitments of health institutions

The new mechanism included obligating private health institutions to 16 key commitments to ensure work discipline, the most important of which are:

• Providing care according to the highest professional and ethical standards without discrimination between beneficiaries.
• Completely refrain from requesting or receiving any money directly from beneficiaries in exchange for insurance-covered services.
• No financial incentives should be offered to doctors or staff in exchange for referring patients to specific departments or institutions, to ensure the integrity of the medical decision.
• Thoroughly verifying the beneficiary's identity and eligibility before filing financial claims.
• The claims management company must be notified of emergency cases within 3 hours of receiving the case, and at most within 24 hours.

Transparency and technical connectivity

The mechanism places a strong emphasis on technical aspects and transparency, aiming to standardize the processes for submitting and processing claims through dedicated online portals. This includes streamlining communication procedures and establishing electronic connectivity to ensure rapid response to complaints and appeals. Furthermore, institutions are obligated to grant the center access to the data necessary for verifying service quality, thereby enhancing oversight and reducing the potential for fraud or misuse.

Expected impact of the decision

This regulation is expected to bring about a qualitative shift in the patient experience within the Kingdom, contributing to reduced waiting times for emergency cases and preventing unjustified financial burdens on citizens and residents. It will also create a fair and competitive environment among healthcare providers based on the quality of care and efficiency of performance, ultimately serving the best interests of public health in Saudi society.