The usual diagnosis
When direct billing fails, the first explanation is usually "Chinese hospitals do not accept international insurance." That is rarely what happened. Most of the hospitals we work with will invoice a payer. What fails is the claim, not the payment.
What actually blocks a claim
- Invoice items and coding. An invoice line that says "treatment" cannot be adjudicated. The payer needs the item, the code and the date, and the hospital billing system was built for a domestic payer.
- Diagnosis coding. A discharge summary written for the family is not a claims document. The ICD code, the procedure code and the narrative have to agree, and they frequently do not.
- Pre-authorisation timing. Authorisation obtained after admission is a denial with a delay attached.
- Language and format. A scanned PDF in Chinese with a red chop is evidence in China and an unreadable attachment in the payer system.
A setup that works
Four things, none of them financial:
- pre-authorisation before the bed is requested, not after;
- one document template agreed with the payer claims team, in their field order;
- one named contact on each side, so a missing item is a phone call and not a ticket;
- a log of every denial reason, reviewed quarterly, because the same reason usually repeats.
What we do not do
We do not adjudicate claims, we do not decide what is covered, and we do not promise a reimbursement percentage. Those decisions belong to the payer. Our job is to make the file adjudicable.
通常的诊断
直付失败时，第一解释往往是"中国医院不收国际保险"。但真实发生的情况很少是这样。我们合作的大部分医院都愿意给付款方开票，失败的是理赔，不是支付。
真正卡住理赔的是什么
- 发票项目与编码。 一行写着"治疗"的发票无法裁定。付款方需要项目、编码和日期，而医院的计费系统是按国内付款方建的。
- 诊断编码。 写给家属的出院小结不是理赔单据。ICD 编码、手术编码与叙述必须一致，而它们经常不一致。
- 预授权时点。 入院之后才拿到的授权，本质上是"带延迟的拒付"。
- 语言与格式。 一份带红章的中文扫描 PDF，在中国是证据，在付款方系统里是一个打不开的附件。
一套能跑通的配置
四件事，没有一件是钱的问题：
- 床位申请之前做预授权，不是之后；
- 与付款方理赔团队约定一套单据模板，按他们的字段顺序；
- 双方各指定一个具名联系人，缺件是一个电话而不是一张工单；
- 记录每一条拒付原因，按季度复盘——同一条原因通常会重复出现。
我们不做的
我们不做理赔裁定，不判断什么在保障范围内，也不承诺报销比例。这些决定属于付款方。我们的工作，是让这份文件可以被裁定。