Auditoria e gestão na saúde suplementar: glosa na visão de uma operadora de planos de saúde de autogestão

Abstract

Introduction: Glosses issued by Health Plan Operators (OPSs) and/or received by healthcare providers bring with them the instinctive perception of administrative processes of non-compliance, deepening the relationship of distrust so present between the participants in supplementary healthcare. Objective: To analyze the gloss profile of a self-managed health plan operator. Method: This is a cross sectional, field, quantitative, descriptive and analytical study, with correlation between variables in a medium-sized nationwide operator. Secondary data was used from the operational and billing system of the Health Plan Operator under study. The population comprised chargeback records, which were analyzed according to the Supplementary Health Information Exchange Standard Domain Table, from 2018 to 2022. The project was submitted for authorization by the Health Plan Operator and complies with Resolution 510/16 of the National Health Council. Data were submitted to descriptive and inferential statistical analysis. Results: There was a 38.60% reduction in the number of beneficiaries in the period from 2018 to 2022; that is, the average gloss rate was 10%/year, the average value/gloss/year was R$550.00, the average gloss value per capita/year was R$932.15. Glosses totaled R$184,850,874.10, with high financial amounts related to hospitalizations and administrative glosses - around R$80.69 million. The most frequent and highest value TISS reason for denials was code 1705, related to a different value between the contracted amount and the amount presented. There was no significant difference between the amounts and rates of glosses related to the Brazilian regions. Conclusion: This study points out to the need for a survey of the reasons for denials within PHOs so that they can be assessed, qualified and quantified. Actions for improvement are imperative; otherwise we will see a multiplication of chargeback rates that could have been resolved in the first instance. Moreover, providing hospital medical billing that can reflect the reality of care without the need for future corrections and/or adjustments, providing a guarantee of revenue and certainty of payment.