Those who have just started in medical clerical work, or physicians preparing to open a practice, are sure to hear the word "rezept check" at least once. A rezept check is the task of reviewing rezepts (statements of medical fees), and it is indispensable for protecting a clinic's revenue. This article gently explains, in a way beginners can understand, what a rezept check is and the methods and flow of rezept review.
What is a rezept check, and why is it necessary?
A rezept check (rezept review) is the task of reviewing rezepts before submitting them to the review and payment organizations, and confirming that there are no entry errors or billing mistakes.
Medical institutions compile the content of the care they provided into rezepts and, each month, submit claims to review and payment organizations such as the "Social Insurance Medical Fee Payment Fund" and the "National Health Insurance Organizations." If there are deficiencies in the entries or billing here, "returns" (in which the rezept is sent back) or "assessments" (in which the points are reduced) occur, causing the clinic to lose revenue it should have received. The rezept check is the last line of defense that prevents these returns and assessments in advance and protects the clinic's revenue.
Understanding the difference between returns and assessments
In understanding rezept checks, the difference between "returns" and "assessments" is basic knowledge worth grasping.
- Return (henrei): When there are deficiencies or unclear points in the entries and the appropriateness of care cannot be judged, the rezept is sent back to the medical institution. You can correct it and re-submit the claim.
- Assessment: When, as a result of review, the care is judged not to conform to the rules of insured care, or to be medically excessive or inappropriate, the points are reduced.
Both can be reduced through proper rezept checks. The criteria for returns and assessments are based on public rules such as the medical fee schedule, and the review approach is also published on the review and payment organization's site (Social Insurance Medical Fee Payment Fund: Flow of Review and Payment Operations).
How to review rezepts (the check perspectives)
Rezept review is performed from two broad perspectives: "formal checks" and "medical checks."
| Perspective | Main check content |
|---|---|
| Formal check | Misentries and missing entries in patient information, insurer number, and symbol/number |
| Billing check | Whether it follows the billing rules, and whether there is missed or excessive billing |
| Diagnosis-name check | Whether there is a diagnosis name corresponding to the care, medication, and tests performed |
| Consistency check | Whether the content of care is consistent with the number of times, days, and dosage |
Particularly common are clerical entry errors and "missing diagnosis names" (no diagnosis name corresponding to the content of care). Many of these can be sufficiently prevented with careful review, and the daily accumulation leads to a difference in return and assessment rates.
The general flow of a rezept check
Monthly rezept operations generally proceed in the following flow.
- Daily entry: Record accurately in the chart and rececon each time care is provided.
- Creating rezepts at the start of the month: Compile the previous month's care into rezepts.
- Rezept check (review): Review formal, billing, diagnosis-name, and consistency aspects, and correct errors.
- Claim (submission): Submit the rezepts to the review and payment organization.
- Handling returns and assessments: If there is a return, correct and re-submit; for assessments, file a re-examination request as needed.
Of these, the burden of "3," reviewing a large volume of rezepts within the limited period at the start of the month, is very heavy and is a cause of overtime for medical clerical staff at many clinics. In recent years, the review and payment organizations have also introduced computer checks and AI-based sorting of rezepts, and efficiency is being demanded of the review on the medical-institution side as well (Social Insurance Medical Fee Payment Fund: Disclosure Regarding Computer Checks).
How AI rezept checks change review operations
Manual rezept checks require knowledge and experience and also take time. This is where AI-based rezept checks demonstrate their power. Pottech's "AI Karte" has an AI-native design that unifies the electronic chart and rececon, and the AI reviews the billing content on the spot as care is recorded, surfacing in advance the risks that tend to lead to missed billing, returns, and assessments. Because the chart and billing data reside on the same foundation, a review that takes into account both the content of care and the billing rules is possible. The review work that had been concentrated at the start of the month can be distributed throughout daily care, greatly reducing the burden on medical clerical staff.
In closing
A rezept check (rezept review) is a crucial task that prevents returns and assessments and protects the revenue a clinic should rightfully receive. Careful review from the perspectives of formal, billing, diagnosis-name, and consistency aspects is the basis, but the burden is by no means small. By leveraging AI-based rezept checks, you can significantly reduce the burden on medical clerical staff while maintaining review quality.
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.