The analysis of contracts in the audit is routine for professionals in this area of health. However, many details and techniques are still unknown to many people. If you want to differentiate yourself, consult the instructions below to analyze the importance of the contract and the step-by-step instructions that must be followed and verified.

In the complementary healthcare sector, we know that written contracts between operators and healthcare providers (clinics, laboratories, hospitals and other institutions) are mandatory. If it does not exist, ANS may apply the penalties provided for in normative resolution RN 124/2006.

A contract is a document signed by the legal representatives of both parties based on an agreement between the two parties.

Therefore, during the audit, it is an important tool to compare the charged content with the agreed content.

The reasons why the contract is so important

According to ANS (2016), the terms contained in the contract define the object and nature, value, invoice payment period and price adjustment (must be annual) of the contracted services, stipulate the penalties for non-compliance with established obligations, the validity and renewal of the contract and termination.

All the rules agreed in the contract between the health operator and the provider help the audit process to become a valuable and very important tool.

What to check in contracts during the audit?

Compensation parameters

The contract contains the entire scope of the service to be provided and the values agreed by both parties for each demand. Daily allowances, fees, equipment rental, medical expenses, procedures, auxiliary diagnostic and treatment services, medicines, materials, etc. can be named.

It is common to use CBHPM table to calculate medical expenses. Brasíndice and Simpro are used for materials and medicines.

Application materials, high-priced drugs, and OPME rules

We must be aware of the rules for requesting expensive materials and medicines, which normally require authorization.

In addition, we must also check the rules related to OPME requirements (ortheses, prosthetics and special materials) before and after surgery.

Invoice, payment date and delivery of resources 

The contract defines the rules for the delivery and payment of invoices and the sending and response of disallowance appeals.

Therefore, as the deadline is specified in the contract, it is very important to check the dates for organizing and optimizing the audit process.

It is clear that the contract is an important audit tool. However, it is not necessary to remember all of your information, but it should always be available when reviewing your health plan provider.

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