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Impact of Medical Insurance Contracts Elements on the Profitability of Hospitals

This study aims at identifying the impact of the elements of medical insurance contracts on the profitability of hospitalsa case study. To this end, the researchers collected the financial statements and the analytical reports of medical claims and the determinants of the origin of these claims (the actual deduction) from the accounts of the Islamic Hospital as well as the contracts and agreements signed between the Islamic Hospital and insurance companies showing the agreed contractual deduction on the hospital services, (The Medical Laboratories Department, Radiology Department, Pharmacy Department, Medical Procedures Department, and Medical Supplies Department) for the period 2006-2016. A set of appropriate statistical methods were applied through the SPSS program. The study results show that the study variable has, to a large extent, an impact on the profitability of the Islamic Hospital. The study provided a set of recommendations, mainly: establishing a division of medical approvals and audits that coordinates between the insured and the insurance company to guarantee the veracity of medical procedures.


Preface
Hospitals are an indispensable sector of services through its role in the society in elements of: providing care and health to individuals, alleviating their pain and ensuring health protection, thus boosting and supporting the national economy by attracting external investments and relevant parties. Governments have a role to play by building hospitals, health centers and clinics that provide services to people unable to pay the high cost of treatment to hospitals and medical centers. In this regard, health insurance companies have provided people with medical services at lower prices.
As health needs and requirements increase, the need for parties with common interests based on certain principles emerges to manage the health insurance process, represented by insurance companies on one hand, and medical service providers on the other hand: hospitals, laboratories, radiology, pharmacies, and other related parties), through the medical insurance contracts between the related parties, and subsequently affecting, through the financial transactions and claims, the financial repayments values between them. This affects the net operating savings, reflected in the financial reports and statements. In the light of the above mentioned, this study is conducted to reveal the impact of the elements of medical insurance contracts on net operating savings.

The Study Problems and Questions
Insurance companies seek to attract a wide range of insured through a quality of performance, and meeting the needs of the latter. Hospitals across the Hashemite Kingdom of Jordan are the main contracting parties with insurance companies, being their mainstay since hospitals are a tool that draws individuals (patients). The work mechanism between insurance companies and hospitals is through contracts or agreements. Hospitals submit the financial claims showing the costs of service provided to patients, to insurance companies as per the agreements signed between both. The financial department, represented by the Medical Insurance Accounting Department, matches the insurance companies payments to the origin of these claims after discounting the contractual deduction. It has been noted that insurance companies have deducted the difference outside of the insurance contract, known as financial claims settlements. That`s the problem between the financial claims submitted by the hospital and what has been recognized by the insurance companies, which may affect the net operating savings of the Islamic Hospital through the elements of the medical insurance contracts concluded with the insurance companies.
Through the above, the researcher presents the study problem through the following question: • Is there a statistically significant effect of the difference between the contractual deduction and the actual deduction of the elements of medical insurance contracts on the net operating savings of the Islamic Hospital?

The Study Hypothesis
"There is no statistically significant effect of the difference between the contractual deduction and the actual deduction of the elements of medical insurance contracts on the net operating savings of the Islamic Hospital at the level of significance (0.05 α≥)."

The Objectives of the Study
The study aims at shedding light on the medical services provided by the elements of the medical insurance contracts concluded between the insurance companies and the Islamic Hospital, which affect the net operating savings of the Islamic Hospital. It examines the financial claims and their actual deductions and calculates the difference between the actual and contractual deduction of these claims and how it affects the Islamic Hospital net operating savings.
Based on the above, the objectives of the study can be defined as follows: 1. Evaluate the impact of medical insurance contracts on the net operating savings of the Islamic Hospital. 2. Identify the elements of the medical insurance contract between the insurance companies and the Islamic Hospital.

The Significance of the Study
This study is of importance as it tackles the elements of medical insurance contracts and their impact on the net operating savings of the Islamic Hospital. It aims to shed light on the impact of the elements of medical insurance contracts on the net operating savings of the Islamic Hospital through the medical services provided and contracted between the insurance companies and the Islamic Hospital. On the other hand, the insurance companies are moving towards achieving the greatest possible returns through the conclusion of medical insurance contracts, thus, generating revenues for the hospital and consequently reflecting positively on the net operating savings of the Islamic Hospital. Being a branch of the Islamic Charity Center in Amman, this hospital enjoys financial and administrative independence. Therefore, the study aims to fulfill the practical side, represented in the difference between the contractual deduction and the actual deduction on the financial claims submitted by the Islamic Hospital to insurance companies, the financial receipts of these claims, and its impact on the net operating savings.

Procedural Definitions
Insurance contracts: "The contract whereby a party (insurance company) accepts an important insurance risk from another party (the policy holder) and agrees to compensate the policyholder for an uncertain definite future occurrence (insured event) that adversely affects the policyholder (IFRs 4).
Insurance companies: A type of financial and insurance institution that has a dual role since it provides the insurance service to those interested, and collects money from the insured to reinvest for a return.
Profitability of Hospital (Net Operating Savings): It represents the net output of the operations executed by the economic unit.
Net operating savings is achieved by subtracting the cost of operating expenses from the total income. Contractual deduction: It refers to the agreed deduction of the elements of the insurance contracts represented by the Medical Laboratories Department, the Radiology Department, the Pharmacy Department, the Medical Procedures Department, and the Medical Supplies Department, as per the agreement signed between the service provider (the Islamic Hospital) and the insurance company.
The actual deduction: It is the deduction on the total claims as stated in the payment details statements issued by the insurance companies and including the contractual and non-contractual deduction and the net payment of the origin of the financial claim.
The hospital: The hospital is one of the most important service and professional facilities that provides integrated medical and therapeutic services through its multiple departments, aiming to serve present and future patients. Medical services are intangible assets, including all services provided to fulfill medical needs, whether these are therapeutic, diagnostic or nursing medical services offered through a variety of means, the most important of which are hospitals. The International Committee of Health Experts has defined the hospital as "an essential part of a social and health organization that provides full therapeutic or preventive, health care to individuals. It is also a center for the training of health workers as well as conducting social biological research.

The Definition of Insurance
Insurance has become one of the basic and essential pillars of social, economic and national life in societies. Since the beginning of time, humans have been working hard to mitigate the damage and dangers that surround and threaten them, in their attempt to reach a state of security and stability for their lives and properties. Insurance is defined as a cooperative venture designed to protect individuals and groups exposed to a specific risk. The risk burden is distributed only among members who cooperate and participate in the insurance process, aiming at mitigating the financial consequences of risk materialization (Hilali et al., 2007).

The Concept of Health Insurance and its Objectives
Health insurance is defined as: "A contract under which the insurance premiums are paid to the insurer who pledges to pay a specific amount or in installments to the insured. The insurer pays all or part of the expenses regarding treatment and medicine in case of illness from the part of the insured" (Abdul Hadi and Al-Sayyd, 2003). Health insurance aims to: 1. Achieve the highest possible level of health and boost the spirit of social solidarity through the provision of comprehensive and integrated medical services to all the community. 2. Set the general principles of how to contribute to alleviating the cost of treatment for families and the State. 3 -Participate in bearing the burden of health risks with the needy, based on social values and norms.

Literature
The researchers have faced some difficulty in their search for previous relevant studies, due to the novelty of the subject. The following are studies in Arabic and foreign languages considered by the researchers to be closest to the subject of the study.

A Study by Sahim et al. (2007), Entitled
(Factors affecting impatient satisfaction: Structural equation modeling) This study aims to determine the factors affecting patient satisfaction in a training hospital in Turkey. The sample included 302 patients residing in the hospital. The factors were analyzed to measure patient satisfaction, and the structural equation was formulated to determine the effect of the patient characteristics (patient satisfaction). Results show that the patient`s level of education and the nature of the treatment provided have an effect on his level of satisfaction. This level is high among surgical patients and patients with a low level of education whereas low among patients with high academic degrees and nonsurgical patients.

A study by Gupta and Denton (2008) Entitled
(Appointment Scheduling in health care: Challenges and opportunities) The study aims to determine the factors influencing the appointment scheduling and its impact on the provision of health services through the arrangement of medical schedules, since this is the policy used in specialized clinics and hospitals primary clinics to facilitate patients access, select appointments easily, be there when service is provided and set the preferable time for both the service provider and recipients, through the use of advanced methods and the experience of the hospital employee. The study succeeded in organizing a schedule for choosing the right time in a scientific and practical way.

(The financial performance of life insurance companies in Ghana)
The study aims at evaluating the financial performance of the insurance industry on the emerging economic life. In his study, the researcher relied on the main determinants such as the profitability of life insurance industry. The study concluded that the total premiums are positively related to the profitability of the insurance companies, and that there is a complementary relation between insurance profits and the investment income of life insurance companies. This study addresses the urgent need to meet the objectives that are critical to the survival, growth and profitability of life insurance companies in emerging economies.

A Study by Abu-Khalifa (2013)Entitled
(The Impact of Quality on Health Care).
This study aims to identify the main obstacles that led to the failure to introduce quality applications and to identify their causes. It also sheds light on the effective role of quality and its effectiveness in improving the performance of the health facility and how this is reflected in the profitability of these facilities owners.. The study concluded that there is a certain amount of interest and personal care for patients, but this interest is weak from the part of the management and employees. The study recommends to enhance confidence between patients and employees through continuous training; to reassure patients that they are in safe hands, work to increase interaction between the medical staff, employees and patients by improving mutual understanding and develop training programs to increase the skill of technical workers in the completion of work through merit, civility and credibility.

A Study by Lewezuk (2015) Entitled
Insurance contracts project for accounting In this study, the researcher relied on presenting the problem of the insurance contracts project as it was before and how to develop this project the( IFRS4) standard as an interim criterion for insurance contracts. The insurance contracts were evaluated with the so called current flows value. The study concluded the main challenges in relation to the insurance contracts project, including measurement problems of insurance assets and problems related to the impact of insurance risks on insurance results. The study recommends that attention should be paid to preparing the insurance contracts standard project regarding the quality of the information and the contents obtained through the accounting system.

Methodology
The researchers used the descriptive analytical approach based on a set of research tools for the purpose of completing the research requirements in both theoretical and field aspects by relying on the data needed to test the research hypothesis through the annual reports issued by the Islamic Hospital for the years 2006-2016 as well as the analytical statements of the actual deductions on the financial claims, and the contracts concluded between the Islamic Hospital and the insurance companies for the purposes of the contractual deduction.

Descriptive Statistical Analysis Results
The main indicators of the annual reports issued by the Jordanian Islamic Hospital for the years (2006 -2016). 1-Islamic Hospital Claims to Insurance Companies for the years (2006)(2007)(2008)(2009)(2010)(2011)(2012)(2013)(2014)(2015)(2016). Results in Table 1 indicate that there has been a significant increase in the financial claims sent to insurance companies, which reflects the importance of the contracts concluded between the Islamic Hospital and insurance companies and their impact on the net operating savings of the Islamic Hospital. It is noted that the average of the claims of the Islamic Hospital to insurance companies for the years (

Hypothesis Testing
"There is no statistically significant effect of the difference between the contractual deduction and the actual deduction of the medical insurance contracts elements on the net operating savings of the Islamic Hospital at a level of significance ( .0.0 ≤ α )" To test this hypothesis, the researcher uses multiple regression analysis to measure the effect of the difference between the contractual deduction and the actual deduction of the medical insurance contracts elements on the net operating savings of the Jordan Islamic Hospital at a level of significance ( .0.0 ≥ α ). The results in Table (6) include the following: The data in the previous table clearly shows that the level of significance value (0.021 = α) is less than the level of significance ( .0.0 ≥ α ), and by comparing the values obtained in testing this hypothesis, the null hypothesis is rejected and the alternative hypothesis stating that "There is a statistically significant effect of the difference between the contractual deduction and the actual deduction of the medical insurance contracts elements on the net operating savings of the Islamic Hospital at a level of significance ( .0.0 ≤ α ) "is accepted. The table also indicates that the variance in the independent variable (R²) explains a percentage of (0.886) of the variance in the net operating savings of the Jordan Islamic Hospital.

Conclusions
Based on the results of the statistical analysis, the researchers reached a number of conclusions as follows: This hypothesis researched the effect of the difference between the contractual deduction and the actual deduction of the medical insurance contracts elements on the net operating savings of the Islamic Hospital. The results of the statistical analysis of this hypothesis showed a statistically significant effect of the difference between the contractual deduction and the actual deduction of the medical insurance contracts elements on the Islamic Hospital net operating savings at a level of significance ( .0.0 ≤ α ). This may be justified by many reasons, including the following in its general form: • Lack of prior approvals from the insurance company.
• Lack of full coverage for the insured (the patient).
• Case and diagnosis not covered by insurance.
• The insurance company's failure to comply with the contract elements in the right way.
Here are some examples of the above: • Many laboratory tests outside the scope of health insurance were considered by the hospital within the scope of insurance, which led to the exclusion of the claim dismissal value, and thus the hospital has covered this value. • Some procedures related to medical tests, radiographs and medicines were not commensurate with the medical diagnosis, as well as not approved by the insurance company, which led to the exclusion of all procedures associated with the claim, which affected the net operating savings. • By studying the settlement of the claims paid by the insurance companies, the researcher found that there were deductions for some radiographs that did not cover the insured (the patient) in whole but in part, as per the insurance policy agreement between the client and the insurance company.

Recommendations
According to the findings based on the results of the statistical analysis, the main recommendations can be summarized as follows: 1. The creation of a special division, independent of medical approvals and audits, which coordinates between the insured and the insurance company to ensure the validity of the medical procedures, as well as the related claims through the presence of a full-time doctor for the purpose of medical approvals and follow-up medical procedures.
2. Following up the adjustment of the value of invoices issued by the hospital according to the contract, and sending the invoice to the insurance company stating the net value after discounting the contractual deduction value to ensure non-effect on the net operating savings..
3. Allocating a department to examine the reasons behind the rejection of some financial claims; to find out the real value to be claimed by the insurance company, and to resolve the differences between the hospital and the insurance company.