In the history of Brazilian healthcare, there has never been a greater concern about the cost of supplementary healthcare. In 5 years, sector expenses rose 40% — or, in raw numbers, 49 billion reais. In this context, medical auditing emerges as a fundamental process for the maintaining the financial health of health plans.

Much of the increase in spending is due to the accelerated growth of technology: imaging tests, such as MRI, and modern medications are increasingly specific and expensive. But technology also helps control expenses, working, for example, in software that supports medical auditing.

Therefore, it is essential that you know the tools that technology provides. In this article, we will talk about how it is revolutionizing the area of medical auditing. We will also address risk management, in association with this sector. Don't stay behind and keep reading to find out more!

Avoiding fraud

When talking about the healthcare sector, it is impossible not to mention the subject of document management. They are part of all medical assistance, involving everything from registration forms to requesting high-cost exams. If you analyze this in a practice, you will notice the enormous volume of forms and documents that are issued in one day. In a health plan, the dimensions increase even more.

Therefore, the medical audit must be intelligent and focused on results and based on the operator's situation. It is unfeasible and excessively expensive to carry out an individual analysis of each request to the health plan; on the other hand, it is equally inappropriate for the operator to be too lenient. In addition to letting processes that deserve to be audited pass by, this also conveys an image of permissibility that increases the future risk of fraud.

It is in calibrating the balance between these two extremes that technology comes into play. Using software, you can define minimum rules for approving a guide. This software then automatically captures cases that match the criteria and validates them. Those who are denied may undergo a second, more thorough audit, which is analyzed on a case-by-case basis.

This solves a lot of manual work that would have to be done in audits of accepted guides. This way, you will focus the current resources you undertake in your audits on the cases that really need them: those that find any divergence between the pre-established rules and the request. This is a quick and efficient way to intelligently allocate your resources and, of course, maintain the operator's financial health.

Maintaining transparency

The medical audit can seem like an unpleasant moment, when there is conflict between the operator and the professional. There is still resistance in the health sector to understanding the need for fiscal balance and spending control. Therefore, software for medical audits does not only benefit the operator. Doctors also have their work made easier.

This is because with the clear and agreed definition of the criteria for guide authorizations, they know perfectly well what to expect. An attentive professional, who checks the service provision contract, can predict which requests will be authorized. You just need to pay attention to the pre-established criteria.

This mainly avoids friction in medical procedures that depend on subjectivity. Nowadays, we are increasingly moving towards medicine that is based on evidence and protocols. This shields the operator from cases in which expensive exams, procedures or medications are not indicated.

Taking your health plan to a new level

Medical audit software is not limited to facilitating the process and transparency. It also offers data that can support the company in future decisions and outline its current outlook. We'll talk a little more about which areas you can optimize with the use of technology.

Agility in authorization

Healthcare is constantly faced with a race against time. When we talk about acute cases, urgency and emergency protocols often do the trick; but even in elective situations, a delay of weeks or months can mean a lot for treatment.

The most classic example is in cancer treatment: most of the time, there are no criteria for including these patients in an emergency care flow. However, if there is a delay in inclusion, we run the risk of the disease progressing. In addition to favoring the judicialization of medicine in these cases, progression also increases the cost of treatment. Therefore, agility is beneficial for both the patient and the operator.

Return on investment

If you still carry out your medical audit manually, you will certainly be surprised by the benefits of technology. In a few months, it is possible to identify a reduction in the cost of the audit process; Furthermore, in the long term, the operator's financial balance benefits from the reduction in fraud. This is what we call risk management, which reduces the incidence of adverse events.

Provision of statistical data

One smart medical audit It does not just depend on criteria and process automation. There are often nuances that make all the difference in the practical scenario. Perhaps one of your protocols is not covering the reality of a certain area, or an epidemic is starting and masking the real indications for requesting tests and treatments.

To evaluate these specific cases, you need data. And, contrary to common sense, statistics is not a cheap process: software in the area, trained professionals and technologies for collecting information are often not cost-effective. However, medical audit software collects data automatically and instantly.

With them, you can analyze all audits carried out retrospectively in your company. You check trends, such as an increase or decrease in requests denied by the service, and see if there are any specific problems. This makes it much easier to identify a protocol failure and act more accurately on its causes.

Medical audit software has several benefits, but by far the main one is the automation of this process. With it, you focus your resources where it matters most, reducing costs and reducing the risk of fraud. In the information age, it is essential that you rely on technology to stand out in the market.

If you are interested in digital medical auditing, we may be the right solution for your operator. SAUDI acts as software that monitors the entire audit process, from request to completion. payment. Have you ever thought about automating your account audit sector? If so, contact us! We look forward to getting to know you better.