The "increase/decrease notice" that arrives from the review and payment organization is a document conveying to the medical institution the content of a rezept's assessment (reduction) or point increase. If you cannot correctly interpret this document, you may not understand why points were reduced and end up giving up on revenue you could have recovered. This article organizes how to read the increase/decrease notice and explains how to recover unacceptable assessments via a reexamination request.
What is an increase/decrease notice?
An increase/decrease notice is a document that informs the medical institution of the content (the number of points increased or decreased, the reasons, etc.) when there is a change in the claimed points as a result of review. It includes information not only on reductions (assessments) but also on cases of point increases. For medical institutions performing online billing, delivery via PDF and the like through the online billing system is becoming standard (see the SSK's guidance for details on the delivery method).
Points on how to read the increase/decrease notice
When checking the increase/decrease notice, pay attention to the following items. For the specific format and the meaning of symbols, always refer to the "how to read" materials published by the SSK.
- Identify the target rezept: Confirm which claim is targeted from the care month, patient, rezept number, etc.
- Content of the increase/decrease: Which procedure, medication, or item was reduced (or increased) by how many points
- Reason: The reason for the reduction. Confirm the symbol or category indicating the reason—indication, excess, billing requirements, etc.
- Impact on the amount: Which payment the reduced portion is reflected in
The starting point is to accurately grasp "which rezept, which item, why, and by how much" was reduced. If this remains vague, even a reexamination request cannot make a persuasive argument.
Recovering assessments via a reexamination request
If you cannot accept the content of the increase/decrease notice, you can request a redo of the review via a reexamination request. If you can show the basis for appropriate care, there is a possibility that the reduced portion will be restored (recovered).
General flow of a reexamination request
- Analyze the assessment content: Identify the reduction reason in the increase/decrease notice and confirm supporting materials such as the chart and test results.
- Prepare the request form: On the reexamination request form, specifically state the target rezept and the reason for objection and medical basis.
- Submit: Submit to the review and payment organization—online or via the prescribed format/method (varies by your institution's billing method).
- Confirm the result: If accepted as a result of reexamination, the reduced portion is adjusted. Confirm via documents such as the reexamination payment adjustment notice.
Points to note
- There is a defined period for the request: A deadline is set for filing a reexamination. Always confirm the specific period in the regulations and guidance of the review and payment organization.
- A mere objection is unlikely to pass: Beyond "the reduction is wrong," it is important to show specifically, based on materials, that medical necessity and billing requirements are met.
- Difference from "withdrawal": Errors related to the review result (such as a missing diagnosis) are handled by reexamination; errors in the claim content unrelated to the review result are handled by withdrawal (see each review and payment organization's guidance for details).
"Reducing" reductions rather than "recovering" them
A reexamination request is an effective means, but preparing and submitting materials takes effort, and it is not always accepted. A more fundamental measure is to reduce the number of rezepts that get reduced.
Pottech's integrated receipt-computer "AI Karte" uses AI rezept checking to detect, from the care-input stage, points prone to reductions—such as inconsistencies between diagnoses and care content and unmet billing requirements. Because care records and billing data reside on the same foundation, missing supporting entries are easier to notice, reducing the very situations that require a reexamination request. In addition, detection of missed billing and billing recommendations help curb the "leakage" that is easy to overlook in the increase/decrease notice.
In closing
The increase/decrease notice is the starting point for learning the content and reasons of an assessment, and reading it correctly is the first step of a reexamination request. Unacceptable reductions can be recovered via a reexamination request by showing the medical basis. At the same time, having a mechanism to create rezepts that are unlikely to be reduced in the first place is the most reliable way to lighten the burden on clerical staff and protect stable revenue.
Through the provision of AI Karte, Pottech serves as the optimal business partner for clinics—supporting not only better working conditions for physicians, nurses, and medical clerical staff, but also helping clinics achieve to the fullest what they want to accomplish.
For details, please do not hesitate to contact us.
References / Sources
- Social Insurance Medical Fee Payment Fund, "How to Read the Increase/Decrease Notice and Various Notices" https://www.ssk.or.jp/seikyushiharai/mikata/seikyushiharai_04.html
- Social Insurance Medical Fee Payment Fund, "Requests for Reexamination, etc." https://www.ssk.or.jp/seikyushiharai/seikyushiharai_07.html
- Social Insurance Medical Fee Payment Fund, "Method for Reexamination Requests (Withdrawal)" https://www.ssk.or.jp/seikyushiharai/iryoukikan_saisinsa/index.html
- Social Insurance Medical Fee Payment Fund, "Q&A on Review" https://www.ssk.or.jp/goshitsumon/goshitsumon_02.html