5 amendments to the health insurance system to reduce patient waiting times in Saudi Arabia

A strategic step towards digital transformation in healthcare

The Saudi Arabian Health Insurance Authority (SAHIA) announced the implementation of five key amendments to the medical coding system used on the national health insurance platform, “Nafees SHIB.” This step is part of SAHIA’s efforts to expedite medical approval procedures for health insurance policyholders and reduce waiting times at hospitals and medical centers, thereby enhancing the quality and efficiency of services provided to beneficiaries.

General context and Saudi Vision 2030

This update is part of a broader transformation underway in the Kingdom's insurance and healthcare sectors, in line with the objectives of Saudi Vision 2030 and the Health Sector Transformation Program. With the establishment of the Insurance Authority by Cabinet Resolution in August 2023, the supervisory and regulatory bodies for the insurance sector were unified, aiming to enhance governance and improve performance efficiency. The "Nafees" platform is the cornerstone of this transformation, serving as an electronic bridge connecting insurance companies and healthcare providers, ensuring a seamless and secure data exchange.

Details of the five amendments and their direct impact

The new amendments focus on activating precise electronic verification mechanisms to ensure the reliability of exchanged data, based on the Australian Medical Coding Standards (ICD-10-AM), which is among the best practices adopted globally. These amendments include the following:

1. Instant verification of the diagnostic code: The new mechanism prevents the transmission of any inaccurate or incomplete diagnostic data between parties.
2. Code matching with the International Classification: The diagnostic code is checked to be consistent with the approved international code list for billing-associated diseases.
3. Service history verification: Ensures a match between the date of provision of medical service and the validity period of the International Classification of Diseases used.
4. Patient data matching: The patient's gender and age are checked to ensure they match the diagnostic code used, in order to reduce human error.
5. Primary Diagnosis Validity: Ensure that the code selected for the diagnosis is allowed to be used as a primary diagnosis within the approved list.

Importance and expected impact on the health sector

These changes are expected to have a multifaceted positive impact. Locally, patients will experience a direct improvement in their experience through faster medical approvals, reducing waiting times and facilitating access to necessary care. For providers, these measures will contribute to a decrease in the rejection rate of financial claims resulting from coding errors and expedite the financial cycle. Nationally, this step enhances the quality of collected health data, supporting strategic health planning and disease control efforts. Regionally, this initiative reinforces the Kingdom's position as a leader in digital health transformation and the application of best international practices, making its health sector more attractive to international investments and partnerships.