In the relationship between service providers and health plan operators, there is a common situation of facing common problems regarding the type of disallowance.

Disallowances are invoicing not received due to refusals from healthcare providers, due to problematic communication situations between medical plans and audits of clinics' medical bills and/or due to inefficiency in the processes that guide due diligence.

In general, disallowances occur when any information regarding a service provided by the provider does not correspond to the management record in the health plan database.

Therefore, it becomes a huge and highly critical problem for laboratories, clinics and hospitals, causing duplicated work and inconvenience, lack of positive performance on a daily basis, delays in receiving the amounts earned and financial precariousness.

This all occurs because the foreknowledge of the recipe remains implied until the specific gloss is used for the current situation, however, not in all circumstances the gloss can be applied.

The majority of health institutions suffer in a harmful way when arising from disallowances that are practiced by medical insurance companies, therefore, the amount that is not paid to the institutions arises from this hospital or medical disallowance.

The moment this unpleasant situation occurs, the effect must be immediate to review the values, which must come from the service provider in question. Therefore, it will be up to healthcare providers to decide whether they will pay or not, and clearly, the result could be non-receipt from the healthcare provider, causing a billing deficit.

This amount that was not collected will cause degrading losses for the institution.

see the success story of Unimed Extremo Sul, which, by implementing a system for auditing medical bills, reduced disallowances by up to 94%!

In this article we will discuss what glosses are, their types, impacts they cause and how to avoid them.

What are Glossaries?

Non-payment for all services provided by clinics, laboratories and hospitals, for example, appointments, clinical analysis and/or imaging tests, hospitalizations, medication, etc., which obtains billing, is called medical or hospital disallowance. by agreements and health operators.

This situation arises for various reasons where the service provider does not produce the correct charge, which may result in amounts above or below the ideal amount that should have been deposited. From then on, the agreement will carry out analyses, repair errors and only transfer the amount that the patient spent on medical and/or hospital procedures.

There are several reasons why a medical disallowance occurs in the healthcare environment, for example, administrative errors, outdated data, imperfections in medical procedures, among other reasons.

Types of Glosses

Glossations are classified as: definitive or temporary. In the case of a definitive hospital disallowance, this does not demonstrate any possibility of being able to recover its revenue, whether in full or in part, which causes the permanent or definitive loss of the financial sector. As for the temporary disallowance, the health institution has the use of devices that will reverse and lead to a review of billed amounts.

Therefore, there are three types of medical or hospital glosses such as administrative, technical and linear. Check out the details about each one below.

Administrative Gloss

Administrative disallowance arises from operational failures or errors in administrative matters, such as the lack of or incorrect completion of authorization forms indicated by the operator. They are also recorded when there are typing errors and incorrect calculations.

This medical or hospital gloss is the most common of the three types, however, it has a high resolution of problems that occur, which are resolved by correcting the data and sending it back to the medical insurance company.

A authorization guide is a form that can be scanned or printed containing data about the health plan user/client, such as description of the procedure that will be carried out and the agreement signed.

In scheduled situations, the authorization form is sent directly to the client's health plan so that it can be properly authorized before carrying out the medical procedure. However, in cases of extreme urgency, this guide may be issued in the agreement, according to the situation agreed with the service provider.

Technical Gloss

Technical glossing occurs when referring to linked services that were provided to the patient/client. In general, the gloss needs to be revised during a medical bill audit to address more subjective issues. Regularly, technical medical gloss occurs during hospital admissions.

They normally involve procedures carried out without a medical prescription, due to lack of procedures and/or information in the medical records, errors in dispensing medications, and lack of record checks from the management responsible for administering the place.

In technical disallowance there is a need for analysis by management professionals and/or the audit of medical bills, but this type of disallowance is rare.

Linear Gloss

Linear disallowance occurs with high frequency and is related to health plans, but there is direct interference in the institutions that provide these services. Therefore, the way to avoid it is through auditing, which should analyze the following issues, such as operational indicators, all billing systems, payment processes carried out and also statistical analysis.

What are the impacts that glosses have on healthcare institutions?

It should be noted that the revenue generated by private health institutions occurs through services provided by health plans. Therefore, hospital or medical disallowance is one of the reasons that causes loss of revenue.

In this sense, the repercussion caused by the types of glosses tends to harm institutions in varying appearances in which finance is the main issue.

In addition to not receiving the amounts for each service provided, the health institution itself must bear all the costs of the procedures that were carried out, and will therefore have to find other devices from new sources, which could compromise any future services.

How to avoid glosses?

A great way to avoid glosses is to invest in new strategies and technologies to help optimize available resources.

The means of preventing occurrences will need to include in practice actions such as: team training, use of electronic medical records, implementation of a good medical bill audit software. These resources facilitate communication and avoid errors that give rise to glosses in healthcare institutions.

As we have seen, disallowances can arise in situations of inconsistencies in filling out medical records, procedures, registrations, records, lack of communication, poor work performance, incongruous analyses, wrong medication prescriptions, etc. Therefore, never fail to maintain the organization of your healthcare provider with good management practices and regular medical bill audits, this will avoid the constant occurrence of any types of disallowances that were mentioned in this article.

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