Glosas hospitalares: um estudo múltiplo de caso em duas instituições privadas

Abstract

The monitoring of disallowances in hospital accounts through the use of indicators has been an important tool for managers in decision making and to ensure the generation of assistance revenue. Knowing the inconsistencies of the records in the patient's record, reasons for disallowances and their impact on preventable financial losses has been challenging in health. Objectives: To analyze the disallowances made by Health Plan Operators (OPS) in two private hospital institutions. Material and Method: This is a quantitative, analytical, field, cross-sectional study, in the multiple case study modality, in 2018, in two hospitals in southeastern Brazil. The sample consisted of payment statements that the OSPs send to hospitals. The disallowance reasons were analyzed according to the Supplementary Health Information Exchange Domain Table (TISS) and through the patient's medical record. For data treatment, the SPSS Statistics software was used, applying descriptive and inferential statistics. Results: Hospital 1 had an average disallowance rate of 10,90% / year and hospital 2 5,44% / year. Disallowances in hospital 1 totaled R$ 322.101,83, of which R$ 221.262,25 (68,70%) for administrative disallowances and R$ 100.839,58 (31,30%) for technical disallowances, in hospital 2 the total was R$ 800.825,05 where R$ 625.856,26 (78,16%) are administrative glosses and R$ 174.968,79 (21,84%) are technical glosses. In relation to the main TISS reasons for technical disallowances, in hospital 1 the greatest financial value was the code 2007 (R$ 81.492,91) of the material item and in hospital 2, the code 9956 (R$ 104.317,46) related to the code range. In both hospitals the value of the technical disallowance in the material item was higher than the medication, being 90,99% and 84,79% respectively. The technical disallowance related to registration in hospital 1 totaled R$ 2.305,61 in nine (8,25%) medical records and in hospital 2 it was R$ 31.181,14 in 43 (20,0%) medical records. However, there was an absence of medical records only in hospital 2, resulting in a financial loss of R$ 3.096,13 (9,92%) for the institution, which does not justify the disallowance. Conclusion: In both institutions, the global disallowance indicator was high, with administrative financial value higher than the technical one, and specifically related to the item of materials. There was financial loss due to the absence of medical records in hospital 2 only. Thus, it is important for the nurse auditor to develop skill in the use of disallowance reasons by the TISS Table, as it results in effective operational gains for the audit and expressive management resulting from standardized communication between OPS and hospitals, managing costs and avoiding losses for both.