If you want to optimize processes and reduce costs at your health plan operator, the best way to achieve these goals is to hire a medical audit software. Let's see how medical auditing has become essential to improve the profitability and quality of healthcare providers? And yet, how do the largest healthcare providers in Brazil carry out their medical audits? Continue reading!

The medical or nursing audit in healthcare providers analyzes the procedures, knowledge and interventions provided by professionals in this section.

In addition to being an important management tool, it also evaluates the processes and services carried out in clinics, offices, laboratories and hospitals and identifies gaps in the legislation that regulates the sector.

According to a survey by National Federation of Supplementary Health (Fena Saúde), ancillary expenses (consultation, hospitalization and other treatments) represented 80% of the operators' revenue.

In this sense, health audits play an important role in reducing operational costs, avoiding hospital brilliance and ensuring that operators do not pay more than they actually owe in a procedural, analytical, intelligent and transparent way.

In this article, we will present the steps that the guide covers in health plan operators and how medical auditing works, which is increasingly important for large healthcare operators to stay on top, increasing their revenues and improving the quality of services provided by the network. accredited. Furthermore, we will reveal the perfect solution used by the biggest ones! Enjoy:

After all, what is the purpose of medical auditing within operators?

In a very objective way, the medical audit will help you implement the best practices to facilitate the control process between operators and their contractors, thus preventing you from paying more than you should.

A clearer view of processes, procedures and costs can be strategic. Health care providers generally do not monitor the clinical status of beneficiaries and miss a GREAT opportunity to implement disease prevention policies, which can result in significant cost savings in the medium and long term, for example.

Health audits can also help uncover medical falsifications, which largely lead to financial imbalances for operators. Not to mention provider fraud, misdiagnosis with deceptive intent, and other assorted problems.

There are different types of audits in health plan operators. Below we present the main ones. Let's see what they are and better understand how each one works:

Prospective audit

Analyzes processes and activities before executing them to avoid fraud and other problems.

She works with authorization, issuing guidelines or regulatory agencies. In this model, the program is analyzed not only for technical aspects, but also for management issues (such as planned coverage or contracting of suppliers).

Retrospective audit

As the name suggests, it is an analysis of the process that the operator carried out, possible failures and successes.

It analyzes the relationship between the number of people who are discharged from hospital (monthly) and the number of medical records, in addition to estimating the actual amounts of bills that exceed a certain amount or estimating by drawing lots and sampling medical records.

Concurrent audit

It consists of the simultaneous use of prospective and retrospective methods, which includes checking the medical records and interviewing the patient to detect the degree of satisfaction with the service.

Concurrent audit

In this model, a team of auditors from the clinic (surgical center) and its operators will settle the expenses of a specific patient every day. To complete this process safely, technology must be used. Its main purpose is to evaluate the quality of the service provided by the health institution and correct potential flaws in this service, comparing whether the procedures, conduct and activities are following established protocols.

Apart from the experience report, we can list the following benefits of concurrent auditing:

• Analysis at the place of hospitalization;
• Surgical center monitoring and other high-cost demands;
• Immediate action;
• Guidance and minimization of doubts from the assistance team;
• Current monitoring;
• Prevent non-conformities/errors;
• Focus and monitoring of the quality of care;
• Monitoring patient satisfaction

Given its importance, concurrent auditing was recently cited in ANS regulation 452, National Health Agency, as a requirement for accreditation of health operators.

Hospital Audits and Glosses

After procedures covered by your carrier's health plan, the hospital or clinic auditor will send an invoice to the plan for the same review process and whether authorize payment.

In case of refusal, the hospital does not allow it, which causes losses for both the clinic and the health plan operator.

Medical audit in the largest healthcare providers in Brazil

The largest Brazilian health plan operators seek technical solutions that help in the execution of all these processes in an automated, transparent and intelligent way. Make the most of the benefits of medical bill audit software, in particular to reduce personnel costs and possible errors caused by human operations.

When hiring the solution, it is important to evaluate whether the medical bill audit system will help you:

• Reduce the flow of billing disputes;
• Optimize the electronic audit of medical bills with the possibility of automated, fast and reliable activities, in accordance with what was contracted – Production Mat;
• Increase the reliability of audits carried out, ensuring traceability in all operations carried out in the system, recording the “who”, “when” and “what” was modified;
• Improve relationships with the provider network, making the presentation of medical bills transparent and quick;
• Improve price negotiation with providers, through better support of historical information on volume of services and prices charged, compared to competitors (Benchmarking) and preparation of service “Packages”.
• Safely increase results even during business growth;
• Reduce accident rates, through a marked improvement in claims controls and better contractualization of the provider network.
• Automate medical and administrative audit processes electronically, quickly and reliably;
• Optimize process flows by identifying and eliminating bottlenecks;
• 100% Eliminate the use of paper from processes in your operation;
• All this with zero implementation costs.

Discover the most awarded and requested medical audit software in Brazil

O SAUDI is a system designed to maintain the “financial health” of Supplementary Health Plan Operators. Used by more than 50 Unimed units throughout Brazil, Bradesco Saúde and other giants in the sector, it is today the most complete and integrable medical audit system.

SAUDI automates this entire process of auditing medical service providers' accounts, enabling a clear view for both sides (operators X service providers) and a significant reduction in unnecessary costs in the first 3 months of use.

Acting throughout the entire process, from requesting authorization for medical procedures from the network of providers, to their respective release for payment, SAUDI's objective is for health plan operators to become healthier and achieve better results through better management of your care costs.

The results are surprising in the first few months of use! And the best part, it has ZERO implementation cost.

Contact us and learn how our customized solutions can deliver significant results in a short space of time!