Efficient management of medical bills is essential for the financial sustainability of clinics, hospitals and healthcare operators. One of the main challenges in this process is the occurrence of medical disallowances, which can result in significant financial losses and increased administrative rework.
In this article, we'll explain what disallowances are, the main reasons why they occur, strategies for avoiding them and a step-by-step guide to appealing efficiently when they do happen. And to find out the solution adopted by the largest healthcare operators Brazilians to eliminate almost 100% of the glosses, keep reading until the end! ; )
What are Medical Glosses?
Medical disallowances are total or partial denials of payments by health insurance companies to service providers such as hospitals, clinics and laboratories. These refusals can occur for a variety of reasons, from billing errors to differences in contractual rules between the parties involved.
Disallowances have a direct impact on healthcare institutions' cash flow and can cause delays and financial difficulties. For this reason, prevention and knowing how to appeal correctly are essential steps to ensure that the services provided are properly remunerated.
Types of Glosses
Disallowances can be classified into different categories according to their origin and reason. The main ones are:
1. Administrative Gloss: occurs due to errors in filling in the billing slip, missing documents or failure to meet deadlines. Example: sending an invoice without the signature of the responsible professional.
2. Technical glossary: related to flaws in the description of procedures, incompatibilities between diagnoses and treatments or lack of justification for certain services. Example: charging for a test without the proper clinical indication.
3. Contract Glossary: arises from non-compliance with the rules established in the contract between the provider and the health insurance company. Example: charging for a procedure not covered by the plan.
Correctly identifying the type of disallowance is the first step to avoiding new occurrences and appealing effectively when necessary.
How to Prevent Medical Gloss?
Preventing denials starts with efficient management of administrative, technical and contractual processes. Some practices can help to significantly reduce payment rejections.
1. Standardization and Staff Training
- Training the professionals responsible for invoicing and auditing medical bills is essential to ensure that all charges are made correctly.
- Constantly updating employees on changes in regulations, contracts and the requirements of health insurance companies.
2. Proofreading and Checking Before Sending
- Establishing a double-checking process for collection slips to avoid administrative errors.
- Check that all the information required by the operators is filled in correctly.
- Confirm that the procedure codes and ICD (International Classification of Diseases) are correct and compatible with the care provided.
3. Use of Management and Automation Systems
• Software specialized in managing medical bills help minimize errors by integrating clinical and administrative information.
- Systems such as Saudi allow electronic auditing, helping to standardize charges and identify possible inconsistencies before they are sent.
4. Pay attention to contractual rules
- Each health insurance company has its own billing rules. It is essential to know and follow these rules in order to avoid contractual disallowances.
- Maintaining an efficient communication channel with operators can help clarify doubts and anticipate possible problems.
5. Complete Documentation and Technical Justifications
- Always attach medical reports, technical justifications and other documents that prove the need for the procedures performed.
- Ensuring that medical records are properly filled out and contain detailed information about the care provided.
Adopting these practices can significantly reduce the rate of disallowances and make the billing process more efficient.
How do I appeal a medical bill?
Even with all the preventive measures in place, some disallowances can still occur. When this happens, it is important to follow a structured process to appeal and ensure proper payment.
Step by step to appeal a disclaimer:
1. identification of the disclaimer
- When you receive the disallowance statement from the operator, analyze each case to understand the reason for the refusal.
- Classify the disallowance as administrative, technical or contractual to define the best appeal strategy.
2. Detailed Analysis of the Occurrence
- Check whether there was an error in sending the bill and, if so, correct the information before resending it.
- Consult medical records, exams and reports to gather evidence to justify the charge.
3. Drawing up the resource
- Prepare a formal document with well-founded arguments, citing standards and clinical evidence where necessary.
- Attach all supporting documentation, such as medical reports, corrected guides and complementary reports.
4. Sending the appeal to the operator
- Follow the procedure established by the operator for sending the appeal (electronically, by post or on a specific platform).
- Make sure that all deadlines set for objections are respected.
5. Follow-up to the Resolution
- Once the appeal has been sent, monitor the status of the dispute with the operator.
- If the appeal is denied, consider the possibility of a new challenge or direct renegotiation with the operator.
In some cases, if the problem persists and the denial is not justified, it may be necessary to contact regulatory bodies, such as the National Supplementary Health Agency (ANS), to mediate the issue.
Discover the solution used by the largest healthcare operators in Brazil
Medical disallowances represent one of the main challenges in hospital account management and can have a direct impact on healthcare institutions' revenue. However, with well-structured processes, the use of technology and staff training, it is possible to significantly reduce the occurrence of disallowances and ensure more efficient billing.
In addition to prevention, it is essential to have a clear flow for appealing denials when they occur, ensuring that the services provided are duly paid for. And this is where SAUDI comes in, a medical bill audit system used by dozens of health operators throughout Brazil.
O SAUDI allows hospitals, clinics and healthcare operators to have more precise control over their charges, drastically reducing the occurrence of administrative, technical and contractual disallowances. With advanced functionalities, the platform enables automated electronic audits, identification of inconsistencies before invoices are sent and greater compliance with the rules of each operator.
If your institution is looking for more efficient medical bill management, the elimination of unnecessary disallowances and more predictable and secure billing, the SAUDI is the ideal solution. Don't waste any more time and money on rework! Contact to find out how SAUDI can transform its management and ensure that each service provided is properly remunerated.
