Validity of claims database compared with the electronic medical record of private health clinics in Malaysia: a pilot study

• Main Authors: Mohd Taufek, Nor Hidayah, Ab Rahman, Norny Syafinaz, Mohamed Nazar, Nor Ilyani, Bux, Siti Halimah, Zin, Che Suraya
• Format: Article
• Language: English
• Published: IIUM Press 2022
• Subjects: RA960 Medical Centers. Hospitals. Dispensaries. Clinics
• Online Access: http://irep.iium.edu.my/96585/7/96585_Validity%20of%20claims%20database%20compared%20with%20the%20electronic%20medical%20record.pdf; http://irep.iium.edu.my/96585/; https://journals.iium.edu.my/ktn/index.php/jp/article/view/107/57
• Institution: Universiti Islam Antarabangsa Malaysia

Introduction: The validity of health insurance claims data in private health sectors has been widely reported in many developed countries to monitor details of private healthcare utilisation. Little is known regarding the data validity of private health care services and insurance claims in Malaysia. This pilot study aimed to validate the claims data from a private health insurance database, using electronic medical records (EMR) at the private clinics as the gold standard. Method: Patients’ data were retrieved from the PMCare health insurance database from 2016-2019 recorded for International Islamic University Malaysia employees. Patients were sampled from the PMCare database and manually compared with data from EMR of selected private panel clinics. Data were analysed for descriptive statistics using Microsoft Excel 2013. Results: A total of four panel clinics consented to the study, and data were available for 2016, 2017 and 2019. The number of observations obtained from 118 patients (male = 63, female = 55) was 386, with the most common diagnosis reported in the PMCare database was acute upper respiratory tract infection (63.6%). Total accuracy between PMCare and EMR data was 91.5%, with an 8.5% difference or inaccuracy. Percentage accuracy was varied between different clinics (A= 92.6%, B=84.7%, C=98.6%, D=82.6%). Conclusion: Data submitted to PMCare claims by private health clinics had high accuracy (>90%) and is acceptable for research and other applications. Future studies should investigate the differences in clinic-based practice for documenting the identified types of discrepancies to improve the accuracy of private health insurance databases.