Out-of-pocket payments in hospital: indicator and analysis through the exchange of supplementary health information
DOI:
https://doi.org/10.33233/eb.v21i2.4988Keywords:
Health Indicators; Nursing Audit; Health Management; Supplementary Health; Electronic Health Records.Abstract
Objective: To analyze out-of-pocket payments by health insurance companies in private institutions to improve the process. Methods: Descriptive, field, cross-sectional quantitative research, in the year 2018, in two hospitals. The non-probabilistic sample consisted of 488 payment statements. Results: The mean rate of global disallowance in hospital 1 was 10.90%/year and in hospital 2, 5.44%/year. As for the types of out-of-pocket payments, in hospital 1, the value was R$ 221,262.25 (68.70%) administrative and R$ 100,839.58 (31.30%) technical, in hospital 2, the value was R$ 625,856.26 (78.16%) administrative and R$ 174,968.79 (21.84%) technical. Regarding the reasons for the out-of-pocket payments, the highest value, in hospital 1, was related to the code 2007 (R$81,492.91) related to material; in hospital 2, code 9956 (R$104,317.46) is related to the code range. Conclusion: In both institutions, the administrative out of pocket payments was greater than the technical one. The monitoring of out-of-pocket payments indicators and the use of the supplementary health information exchange provided nurses with agility in their work and better financial management.
References
Rodrigues JAR, Cunha ICKO, Vannuchi MTO, Haddad MCFL. Out-of-pocket payments in hospital bills: a challenge to management. Rev Bras Enferm 2018;71(5):2658-66. doi: 10.1590/0034-7167-2016-0667
Agência Nacional de Saúde Suplementar [Internet]. Rio de Janeiro (RJ): ANS; 2016 [cited 2019 Set 15]. Cartilha de Contratualização Glosa [aproximadamente 5p]. Available from: http://media.wix.com/ugd/61b88b_64dd5a610af84cf19fc88b6ad2625079.pdf
Santos MP, Rosa CDP. Auditoria de Contas Hospitalares: Análise dos principais motivos de glosas em uma instituição privada. Rev Fac Ciênc Méd Sorocaba [Internet]. 2013 [cited 2019 Set 14];15(4):125-32. Available from: https://revistas.pucsp.br/index.php/RFCMS/article/view/17653
Guerrer GFF, Lima AFC, Castilho V. Study of billing audits in a teaching hospital. Rev Bras Enferm 2015;68(3):358-63. doi: 10.1590/0034-7167.2015680306i
Viana CD, Bragas LZT, Lazzari DD, Garcia CTF, Moura GMS. Implantação da auditoria concorrente de enfermagem: um relato de experiência. Texto Contexto Enferm 2016;25(1):e3250014. doi: 10.1590/0104-070720160003250014
Figueiredo T, Silva PLN, Guimarães CF, Freitas L, Guimarães CF, Oliveira MKS, et al. Avaliação dos Registros de Enfermagem de pacientes internados na clínica médica de um hospital universitário do norte do estado de Minas Gerais. Rev Pesqui Cuid Fundam 2019;11:390-6. http://10.9789/2175-5361.2019.v11i2.390-396
Nomura ATG, Barragan MS, Almeida MA. Quality of nursing documentation before and after the Hospital Accreditation in a university hospital. Rev Latinoam Enferm 2016;24:e2813. doi: 10.1590/1518-8345.0686.2813
Morais ER, Gonçalves GL, Amaral MS. Importância das anotações de enfermagem na auditoria: uma revisão bibliográfica. Rev Cient FacMais [Internet]. 2017 [cited 2019 Set 14];9(2). Available from: http://revistacientifica.facmais.com.br/wp-content/uploads/2017/09/4.-IMPORT%C3%82NCIA-DAS-ANOTA%C3%87%C3%95ES-DE-ENFERMAGEM-NA-AUDITORIA-UMA-REVIS%C3%83O-BIBLIOGR%C3%81FICA.pdf.
Borges FFD, Azevedo CT, AmorimTV, Figueiredo MAG, Ribeiro RGM. Importance of nursing records according to nursing team: professionals and institutional implications. Rev Enferm Cent.-Oeste Min [Internet]. 2017 [cited 2019 Out 30];7. Available from: http://www.seer.ufsj.edu.br/index.php/recom/article/view/1147/1311.
Zunta RSB, Lima AFC. Audit and account billing process in a private general hospital: a case study. Rev Eletrônica Enferm [Internet]. 2017 [cited 2019 Out 14];19. Available from: https://revistas.ufg.br/fen/article/view/42082/24697
Spigolon DN, Lima AM, Teston EF, Maran E, Costa MAR, Derenzo N. Impact of the nonconformity of nursing notes in the context of hospital. Ciênc Cuid Saúde 2019;18(1)e44748. doi: 10.4025/cienccuidsaude.v18i1.44748
Resolução Normativa -RN nº 305, de 09 de outubro de 2012. Esta Resolução estabelece o Padrão obrigatório para Troca de Informações na Saúde Suplementar - Padrão TISS dos dados de atenção à saúde dos beneficiários de Plano Privado de Assistência à Saúde [Internet]. [cited 2022 Apr 5]. Available from: http://www.ans.gov.br/component/legislacao/?view=legislacao&task=TextoLei&format=raw&id=MjI2OA==
Agência Nacional de Saúde Suplementar. Padrão TISS. Organizacional [Internet]. Rio de Janeiro (RJ): ANS; 2017 [cited 2019 Ago 20]. Available from: http://www.ans.gov.br/images/stories/Plano_de_saude_e_Operadoras/tiss/Padrao_tiss/tiss3/Padrao_TISS_Componente_Organizacional_201704.pdf
TISS. Troca de Informações em Saúde Suplementar. Manual de Conteúdo e Estrutura. Instruções para preenchimento das guias em papel. Versão 2.1.10 [Internet]. Rio de Janeiro (RJ): ANS; 2010 [cited 2019 Out 14. Available from: http://www.ans.gov.br/images/stories/Plano_de_saude_e_Operadoras/tiss/Padrao_tiss/manual_de_conteudo_e_estrutura_v2110.pdf
Agência Nacional de Saúde Suplementar. Operadoras com registro ativo [Internet]. Rio de Janeiro (RJ): ANS; 2001 [cited 2019 Set 15]. Available from: http://www.ans.gov.br/anstabnet/notas_operadora.htm
Agência Nacional de Saúde Suplementar. Tabelas de Dominio TISS [Internet]. Rio de Janeiro (RJ): ANS; 2007 [cited 2019 Out 14]. Available from: http://www.sbpc.org.br/upload/conteudo/320070521124247.pdf
Dornelles TS, Gasparetto V. Gerenciamento de processos: estudo em uma organização hospitalar Catarinense. Rev Gest Sist Saúde [Internet]. 2015 [cited 2019 Abr 20];4(2):57-72. Available from: http://www.revistargss.org.br/ojs/index.php/rgss/article/view/159/163
FAROL. Glosas [Internet]. Rio de Janeiro (RJ): SINDHRio; 2009 [cited 2019 Out 14]. Available from: http://programafarol.com.br/index.php/ficha-tecnica-dos-indicadores/indicadores-hospitalares/indicadores-administrativos/9-uncategorised/78-glosas
Souza ENC, Santos CH, Higashi P, Souza IF. Processo de auditoria de contas em um hospital público: mapeamento das glosas técnicas em cirurgias ortopédicas. Rev Adm Saúde [Internet]. 2018 [cited 2019 Set 15];18(73). Available from: http://www.cqh.org.br/ojs-2.4.8/index.php/ras/article/view/145/197
Cintra GMG, Souza CG, Souza MGS. Auditoria em Contas Médica no Hospital da Policia Militar de Pernambuco. Id on Line Rev Psic [Internet]. 2016 [cited 2019 Set 15];10(30 Supl 1):93-106. Available from: https://idonline.emnuvens.com.br/id/article/view/431/541
Chavarria CT. Desarrollo e implementación de una herramienta para la validación de cuentas médicas y gestión de glosas en el sector salud en Colombia. Medicina UPB 2018;37(2):131-41. doi: 10.18566/medupb.v37n2.a07
Saranto K, Kinnunen UM, KiveKäs E, Lappalainen AM, Liljamo P, Rajalahti E, et al. Impacts of structuring nursing records: a systematic review. Scand J Caring Sci 2014;28(4):629-47. doi: 10.1111/scs.12094
Silva JASV, Hinrichsen SL, Brayner AC, Vilella AS, Lemos MC. Glosas hospitalares e o uso de protocolos assistenciais: revisão integrativa da literatura. Rev Adm Saúde [Internet]. 2017 [cited 2019 Set 15];17(66). Available from: http://cqh.org.br/ojs-2.4.8/index.php/ras/article/view/13/24
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