Introduction
Hospitals are among the community’s largest health and medical care providers [1, 2]. They absorb significant resources in the health and treatment sectors [3]. According to a World Bank study, 50% to 80% of health resources in developing countries are consumed by hospitals [4, 5]. Therefore, one of the hospital managers’ concerns is controlling the hospital’s financial status and securing necessary resources [6, 7, 8]. Like other developing countries, Iran faces severe constraints on resources. Efficient use of resources is considered an integral part of health system management [8]. Identifying and reducing unnecessary and non-essential costs can enhance efficiency in various health system components, including hospitals [9]. One of the major financial problems in hospitals is delays in receiving claims from insurance organizations and excessive deductions labeled as insurance deductions.
With the adoption of universal insurance laws and the prevalence of health insurance, the provision and sale of services to insured individuals under the coverage of insurance organizations have become a significant part of the income sources for hospitals [10]. Thus, insurance companies constitute one of the main financial resources for hospitals [11]. Therefore, a significant portion of hospitals’ financial resources should be claimed from insurance companies [12]. After reviewing financial documents, insurance organizations deduct monthly amounts under the label of deductions from hospital claims [13]. This dissatisfaction arises because deducted amounts form part of the hospital’s income that is not deposited into its account [14]. In a situation where hospitals are financially strained, a high level of insurance deductions is unacceptable to hospital managers because it reduces the quality of services provided by hospitals and ultimately causes dissatisfaction among patients [15]. This condition underscores the importance of officials paying attention to transparency in preparing and submitting medical documents and financial resources to insurance companies [11, 16].
Numerous studies have been conducted on the causes of insurance deductions. In these studies, the most common causes include incomplete documentation, unfamiliarity with the hospital information system, incomplete registration, entering insurance codes incorrectly, exaggeration, miscalculation, and insufficient staff training [17-21]. In developed countries, companies and insurance organizations refer to deductions as improper reimbursements of medical invoice costs. A report published by the Medicare and Medicaid Services in the United States in 2018 indicated that the rate of improper payments was approximately 5.9% of the total amount paid for invoices, which amounted to $36 million out of a total of $390 billion [21]. Some studies have shown that the major cause of inpatient deductions in Iran is related to deductions in the documentation process. In contrast, in foreign studies, the most significant cause of deductions is the non-inclusion of services in insurance contracts due to the implementation of intelligent digital documentation systems and the design of appropriate payment mechanisms that eliminate many other causes [22, 23].
Financial statistics in university affairs indicate that approximately 4% to 8% of the amounts related to documents sent by university hospitals are deducted by contracted insurance organizations. A detailed examination of the causes and extent of deductions is necessary for planning to reduce deductions, increase revenues, and provide adequate resources for desirable services to patients.
Due to its nature as the only rehabilitation hospital at the national level, Rafeideh Rehabilitation Hospital faces unique challenges. The lengthy stay of patients, lack of insurance coverage for many rehabilitation services, inconsistency in basic insurance in accepting or rejecting insurance prescriptions, and the absence of clear guidelines and policies from insurance companies are among the problems that affect the economic conditions of the hospital. This study aims to determine the extent and causes of deductions in Rofeideh Rehabilitation Hospital. The results of this research can highlight the points in the hospital that lead to deductions by insurance organizations. Additionally, assessing the relationship between the documentation of administrative and preclinical staff, physicians, and nurses with insurance deductions guides hospital managers to a better and more detailed understanding of the causes of deductions. This situation, in turn, can lead to planning to reduce deducts and increase revenues. An innovation in this study is its examination of the causes of insurance deductions in Rofeideh Rehabilitation Hospital, the only rehabilitation hospital in the country with unique challenges compared to other hospitals.

Materials and Methods
This analytical descriptive study was conducted cross-sectionally to investigate the extent and causes of deductions in inpatient files covered by Iran Social Security Insurance in 2021. The study was conducted on 776 discharged inpatient files from Rafideh Rehabilitation Hospital, selected through a census approach. Rafideh Rehabilitation Hospital, the only rehabilitation hospital in the country, has been operational since 2014, providing services in both outpatient and inpatient settings.
In outpatient setting, rehabilitation units such as physiotherapy, occupational therapy, speech therapy, audiology and balance, and orthotics and prosthetics, along with clinics in physical and rehabilitation medicine, hand and peripheral nerve surgery, restorative and speech defect surgery, neurology, pediatric neurology, brain and nerve surgery, internal medicine, adult and pediatric orthopedics, infectious diseases and wounds, geriatrics, palliative and pain medicine, cardiology, palliative care, and psychology are actively providing services. In the inpatient setting, services are provided in neurology, surgery, stroke, pediatrics, and brain and spinal cord injuries.
The hospital’s operating room performs rehabilitation surgeries in orthopedics, pediatric orthopedics, hand and peripheral nerve surgery, spinal surgery, and speech rehabilitation surgeries. Patients with spinal cord injuries, brain injuries, strokes, multiple sclerosis, cerebral palsy, and other disabling sensory and motor diseases make up a significant portion of the hospital’s patient population.
In this study, the inclusion criterion was all files covered by Social Security Insurance, and the exclusion criterion was files covered by other insurances. Data were collected using reports from hospital insurance specialists through the hospital information system (HIS) software. The data included patient files, invoices, and the categorization of hospital deductions by type (visit, consultation, operating room, laboratory, radiology, paraclinical, drug, operating room, and hoteling). Deducts were identified on a monthly basis for the specified year. The causes of deductions were extracted by examining the findings obtained, consulting with Social Security Insurance representatives and hospital insurance specialists, and conducting interviews with unit managers using a checklist.
Finally, the relationship between the documentation of administrative and paraclinical staff, physicians, and nurses with insurance deductions was assessed using a questionnaire previously used in a study by Mohammadkhani et al. (2013), whose reliability had been validated [24]. The questionnaire consisted of 3 questions related to the documentation of nurses, 12 questions related to the documentation of physicians, and 16 questions related to the documentation of administrative and paraclinical staff. Responses were in the form of “yes” or “no”. Data from the questionnaire were analyzed using descriptive statistics (frequency and percentage) and the Spearman correlation coefficient. The results were presented in comparative tables. SPSS software, version 23 was used for statistical calculations.

Results 
The research was conducted at Rofeideh Rehabilitation Hospital, affiliated with the University of Social Welfare and Rehabilitation Sciences. Table 1 presents the amount of insurance deductions for hospitalized patients, categorized by month, in 2021.


The examination of deficiency amounts showed that the total amount of insurance deductions related to hospitalized patients during the year was equal to 1811 million Rials, meaning that 76.3% of the cases in 2021 had deductions. The highest frequency of hospitalized prescription deducts was in October 2021 (48.7%), and the lowest was in April 2021 (38.3%).
The research findings indicated that the highest deductions were related to drug and consumable items, with 310815448 Rials, and surgical procedure fees, with 187728448 Rials. The lowest deductions were related to hoteling, amounting to 1935560 Rials (Table 2).


For a better understanding of the deficiency amounts, they are also presented in Figure 1. The study results showed that the most common cause of deductions was additional requests, with an amount of 281163295 Rials, and the least common cause was documentation errors, with an amount of 88589265 Rials (Figure 2). To address the research hypotheses, the relationship between nursing, physician, administrative, and paraclinical staff documentation and the increase in deductions was tested to determine whether there is a significant relationship. The results showed a significant correlation between nursing and physician documentation and an increase in insurance deducts (P<0.001) (Table 3).



Discussion
Given the insurance laws, there are often disputes in the provision of services and, consequently, in the payment and receipt of insurance claims between insurance companies and hospitals. These disputes are exacerbated due to the nature of rehabilitation services provided by Rofeideh Hospital and the fact that, according to the relative value book of health services, many rehabilitation services are not covered by insurance. Additionally, the prolonged hospitalization of patients poses a constant challenge between these hospitals and insurance companies. Iran Health Insurance Organization has recently taken measures to include some inpatient rehabilitation services under coverage. They have defined service packages for each illness, covering them under their insurance.
This study examined insurance invoices from Social Security Organization in the inpatient rehabilitation section of Rofeideh Hospital. After identifying the reasons for deductions, their correlation with the documentation by the staff was critically analyzed. The study revealed that the highest amount of deductions in Social Security insurance invoices was related to drug and consumable expenses and surgical fees. The leading cause was identified as excessive requests and incorrect coding. The study conducted by Moalemi in 2012 compared the causes of deductions in insurance-covered inpatients’ files between two hospitals, Bahonar and Arjmand, in Kerman City, Iran. Similar to our findings, the study showed that most deductions were related to drug expenses, with the main cause being excessive requests [25]. A study by Safdari et al. on 15 hospitals affiliated with Tehran University of Medical Sciences also indicated that drug and consumable expenses and surgical fees were the most significant factors leading to deductions. The study identified shortcomings in the overall surgery description, patient registration, admission date, and procedure [14]. Results from research by Ariankhesal et al. in 2017 indicated that consumables and surgical fees had the highest deducts in inpatient files, with errors in calculations, lack of hospital supervision, and issues related to document dates and times being significant reasons [7].
The study by Mousa Zadeh et al. on deductions in the inpatient files covered by the Iran Health Insurance Organization showed that the highest amount of deductions was related to surgical fees, and the main cause was excessive requests [26]. Rezvanjou et al., in their investigation of deductions in the invoices of the Social Security Organization and medical services in two hospitals in Tabriz City, Iran, also identified surgical service fees as the most significant source of deductions [27].
In their study on teaching hospitals, Maleki et al. identified the overpricing of medications as one of the major causes of deducts in teaching hospitals [1]. The results of investigations into prescription deductions at Al-Zahra Hospital did not align with the present study’s findings, as the primary causes of prescription errors were identified as having an unclear or tampered date, past/future date issues, or lack of date [28]. This discrepancy might be attributed to the educational nature of Al-Zahra Hospital, where students and interns carry out documentation, and insufficient training on their part leads to documentation lapses.
The nature of rehabilitation at Rofeideh Hospital and the lack of recognition of the hospital’s activities, even by the healthcare system, complicate the challenges in reimbursement from insurance. One of the significant problems is the extended duration of patient hospitalization, which can last up to 63 days. Social Security Insurance does not cover services provided after 21 days of patient hospitalization, which is a major reason for excessive requests in the drug and consumable section. Another major issue in insurance deductions is related to surgical fees. Precise adherence to guidelines and regulations set by the Social Security Insurance Organization is crucial for the hospital’s financial claims.
The findings of our study indicate a direct relationship between the documentation by physicians and nurses and an increase in insurance deductions. Fathi demonstrated that defective documentation by physicians and nurses is one of the main causes of deducts [29]. However, Davis attributed responsibility for determining the role of complete documentation in hospital expense payments to medical document officials [30]. Ghaed et al.’s research showed that a significant portion of deducts was due to the lack of sufficient skills in documenters, mistakes made by the healthcare team in documentation, and non-approval by documenters, especially physicians [8]. Imani et al. also demonstrated that physician documentation is one of the causes of deducts in Tabriz hospitals, with the lack of familiarity with declared tariffs and lack of coding skills being the reasons [21]. Tavakoli et al. found that the treatment team’s incomplete documentation of patient records was one of the most important reasons for deductions [28]. Ariankhesal et al.’s study revealed that physicians and nurses play the most significant role in creating deductions [7].
The surgical operation report form is the basis for billing surgical fees by insurance organizations, and the responsibility for recording data lies with operating room nurses and ward secretaries. In contrast, the surgeon’s responsibility is to register the operation description completely. It can be said that the main reason for deductions in this area is documentation inadequacy. In a study by Mousa Zadeh et al., most factors contributing to deductions were related to inaccuracies in service calculation and incomplete documentation [26]. Since human error exists in all fields, using electronic systems in this area is very beneficial. Howard et al. have found the use of computer systems and their effective role in improving documentation quality and reducing medical errors to be significant. They believe that these systems can inform users about file deductions through alerts, leading to a reduction in insurance deductions [31].
The most significant limitation of the present study was the lack of recording reasons for some deductions in patients’ records or assigning codes to records with insurance deductions by social insurance experts, which was unknown to hospital insurance experts.

Conclusion 
Accurate documentation in medical records significantly impacts the amount reimbursed by insurance organizations and prevents insurance deductions. Considering the significant relationship between documentation by physicians and nurses and the increase in insurance deductions, it is recommended that training courses be conducted for nursing and medical staff. One of the reasons for assigning the code “excessive request” was related to the prolonged stay of patients. In this regard, it is suggested that hospital officials hold sessions with managers of the Social Security Organization to justify the provision of services to rehabilitation patients and the reasons for the prolonged stay of such patients. Since the records are registered in the HIS (Hospital Information System) and the Ministry of Health has initiated a project for electronic registration of inpatient documents by health insurance, it is recommended that the Social Security Organization provide the necessary infrastructure for the start of this project and take the necessary steps for electronic registration of insurance deducts. As many rehabilitation services are not covered by insurance, and payments in this area are generally made out of pocket, the Social Security Organization should define service packages similar to the Iran Health Insurance Organization, covering all services, whether rehabilitation, diagnostic, or therapeutic, under insurance coverage. Insurance experts from the Social Security Organization indicate the causes of deducts by registering numeric codes on patient records, which are unknown to hospital insurance experts. To address this issue, it is recommended that the Social Security Organization take necessary steps to educate its experts on identifying these codes.

Ethical Considerations
Compliance with ethical guidelines
This study was approved by the Ethics Committee of the University of Social Welfare and Rehabilitation Sciences (Code: IR.USWR.REC.1399.171).

Funding
This research was supported by the research project, Funded by the University of Social Welfare and Rehabilitation Sciences.

Authors' contributions
Study design, conceptualization: Seyedeh Mahboubeh Hosseini Zare; Methodology, validation, and data analysis: Mehdi Basakha and Parvaneh Esfahani; Investigation and analysis: Jafar Babapour and Seyed Mehdi Mohsenzadeh; Project supervision and management: Bijan Khorasani; Writing: Seyedeh Mahboubeh Hosseini Zare; Editing and finalization: Seyedeh Masoumeh Hosseini Zare; Research and resources: Najmeh Ashouri.

Conflict of interest
The authors declared no conflict of interest.

Acknowledgments
The authors express their gratitude to the staff and officials of Rofeideh Rehabilitation Hospital for their assistance in this research.


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