"Assessment" and "return"—both are occurrences that can arise in rezept billing, but they differ completely in meaning and handling. If you cannot correctly distinguish the two, you may respond incorrectly and lose revenue you could have recovered. This article organizes the difference between assessment and return, then summarizes practical measures to prevent point reductions (assessments).
The difference between assessment and return
First, let us grasp the basic difference between the two.
| Item | Return | Assessment (reduction) |
|---|---|---|
| Content | The rezept is sent back | The claimed points are reduced/assessed |
| Handling of the claim | Held once, corrected and reclaimed | The reduced portion is, in principle, not paid |
| Main response | Correct and reclaim via the return file | File a reexamination request if you disagree |
| Notice | Return breakdown, etc. | Increase/decrease notice, etc. |
A return is when the review and payment organization sends back to the medical institution a rezept with deficiencies or doubts; correcting and reclaiming it triggers review again. An assessment (reduction), on the other hand, refers to the points being reduced when the review judges that the claimed content does not conform to billing rules, etc. If you cannot accept an assessment, you can raise an objection through the procedure of a reexamination request (see the SSK's official materials for details of the definitions and procedures).
Why do assessments (reductions) happen?
The main backgrounds to assessment include the following.
- Inconsistency with the indication/diagnosis: No indicated diagnosis for a medication or test
- Care judged excessive: The count, frequency, or amount is deemed medically excessive
- Unmet billing requirements: Requirements for additions or management fees are not met
- Insufficient entry/basis: Inadequate required symptom notes or reason statements
In many cases, the cause lies not so much in "the care itself" as in "how it is explained on the rezept." The important point is that even appropriate care can be reduced if the basis is not shown on the rezept.
Measures to prevent reductions
The key to preventing assessment is to create rezepts that do not draw doubts in review. Keep the following points in mind daily.
1. Align diagnoses with the content of care
Assign, without omission, the indicated diagnoses corresponding to each medication, test, and procedure. "Placeholder diagnoses," and conversely leaving unnecessary diagnoses attached, are also factors in assessment and returns.
2. Show the basis with symptom notes
For high-cost tests or care with a higher-than-usual count or amount, explain why it was necessary via symptom notes. When medical necessity comes across, the assessment risk drops.
3. Confirm billing requirements
Additions and management fees can be billed only once the requirements—facility standards, required entries, content performed, etc.—are met. Make it a habit to confirm the requirements and the necessary entries as a set.
4. Systematize pre-submission inspection
Rather than relying on individual memory and experience alone, having a checking mechanism is a stable measure. Because rules change with every medical fee revision, a system that can reflect the latest billing rules is desirable.
Toward "rezepts less likely to be reduced" with AI rezept checking
The difficulty in preventing reductions is inspecting the enormous set of billing rules by hand every time without omission. Pottech's integrated receipt-computer "AI Karte" uses AI rezept checking to detect, from the care-input stage, points such as inconsistencies between diagnoses and care content, unmet billing requirements, and missed billing. It also recommends billable items, which helps not only "prevent reductions" but also "prevent revenue from slipping away." Before contesting an assessment via a reexamination request, creating rezepts that are unlikely to be reduced in the first place is the most efficient measure.
In closing
Assessment and return are distinct things that differ in both meaning and handling. Returns are handled by correction and reclaiming, and assessments are contested via reexamination requests as needed; but for both, "not causing it" rather than "responding after it happens" leads to a fundamental reduction in burden. By keeping the three points—diagnoses, symptom notes, and billing requirements—in mind and having pre-submission inspection as a system, you can achieve rezept operations that are unlikely to be reduced.
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, "Flow of Medical Fee Review and Payment Operations" https://www.ssk.or.jp/shinryohoshu/gyomuflow/index.html
- 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, "Q&A on Review" https://www.ssk.or.jp/goshitsumon/goshitsumon_02.html