Hospital admission authorization (AIH) is a highly bureaucratic process for a health insurance company, due to the need to ensure compliance with regulations, verification of health insurance coverage, analysis of medical documents and coordination between different parties involved, such as the hospital, the health insurance company and the patient. These processes seek to ensure that the hospitalization is appropriate, avoiding unnecessary costs and guaranteeing the quality of care. In addition, the AIH has an impact on the use of medical resources, which need to be audited.
The main objective of hospital admission authorization is control over all the resources used to treat the patient during their hospitalization. This information is decisive for the public or private provider that offers this structure.
As this is a complex procedure, there can be failures or difficulties in managing hospital admission authorizations, resulting in additional expenses or waste that affect operational efficiency. It is therefore crucial to have the right structure in place to avoid such setbacks.
Rules for authorizing hospitalization
The rules for authorizing hospitalization involve presenting detailed medical documents, such as clinical reports and prescriptions. It is essential to confirm health insurance coverage for the planned hospitalization, following specific protocols. In addition, obtaining prior approval from the health insurance company is a critical step, ensuring that the authorization process follows the established rules, avoiding complications and ensuring an effective hospitalization.
The issuance of a hospital admission authorization must follow guidelines established by the National Health Agency - ANS. Initially, it is essential to issue a medical report along with the hospital admission authorization. The doctor is responsible for filling it out, including information identifying the patient, symptoms, test results and conditions that justify hospitalization. The rules for issuing the authorization also include the correct completion of a report on the use of OPMEs (orthoses, prostheses and special materials) as required.
This document is used to properly charge for the use of hospital equipment.
Finally, another important document associated with hospitalization authorization is the medical report requesting administrative discharge. [a][b]
Types of hospital admission authorization
There are various types of authorization for hospitalization, each meeting specific needs. Medical authorization is essential and requires the issue of a report detailing the patient's condition, symptoms, tests and justification for hospitalization. Administrative authorization, on the other hand, involves approval by the health insurance company, taking into account coverage, waiting periods and protocols.
In addition, in specific situations, there is authorization for surgical procedures, which requires a detailed analysis of the procedure, its indications and possible alternatives. Authorizations for the use of orthoses, prostheses and special materials (OPMEs) are necessary in cases of interventions involving these devices.
Elective hospitalization requires prior authorization, planned in advance, while emergency hospitalization occurs in emergency situations and authorization is obtained retroactively. In all cases, strict compliance with ANS rules is essential to guarantee the validity and efficiency of the hospital admission authorization process.
The importance of filling out an AIH correctly
Filling out a hospital admission authorization correctly is crucial for several reasons. Firstly, it contributes to the accuracy of medical information, providing a clear understanding of the patient's condition, symptoms and justification for hospitalization. In addition, correct documentation facilitates analysis and approval by the healthcare provider, avoiding delays and guaranteeing adequate coverage.
Authorization also needs to ensure that surgical procedures and the use of special devices (OPMEs) comply with the rules, minimizing risks and optimizing treatment. In cases of elective hospitalization, proper completion is essential for efficient planning, while in emergency hospitalization, retroactive documentation helps speed up the process.
Correctly filling out the hospital admission authorization not only meets bureaucratic requirements, but also guarantees the effectiveness, safety and appropriateness of medical treatment, benefiting both patients and healthcare professionals.
How to optimize this process
To optimize the work with hospital admission authorization, the ideal is to implement a system that takes the following practices into account:
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- Process Standardization:
Establish standardized procedures for filling out, sending and processing authorizations, reducing errors and speeding up the flow.
2. Integrated system:
Use an integrated healthcare management system to make it easier to monitor the status of authorizations, minimizing delays and improving operational efficiency.
3. Team training: Provide regular training for medical and administrative staff to ensure that they understand the rules, procedures and the importance of filling them out correctly.
4. Electronic documentation:
Adopt electronic documentation to reduce the use of paper, making it easier to store, retrieve information and share data securely.
5. effective communication:
Establish efficient communication channels between the medical team, health operators and administrative sectors to quickly clarify doubts and resolve problems.
6. Process automation:
Consider automating repetitive tasks, such as checking coverage and validating documents, to speed up the authorization process.
7. continuous monitoring:
Implement a continuous monitoring system to track the status of authorizations, identify possible bottlenecks and act proactively.
By incorporating these practices, it is possible to improve efficiency, reduce errors and provide a more agile and satisfactory experience in the work of authorizing hospital admissions.
Avoid improper and undue medical bills
Errors and fraud can occur in hospital admission authorizations, generating major losses for your health insurance company. Check out the various ways this can happen:
1. Incorrect information:
Simple errors, such as incorrect patient data or medical procedures, can result from inaccurate or misinterpreted information.
2. document forgery:
Fraud can occur through the presentation of falsified or manipulated medical documents, seeking to obtain undue authorizations.
3. Misinterpretation of Rules: Ignorance or misinterpretation of the rules established for authorizations can lead to mistakes in the documentation.
4. collusion between professionals:
Dishonest collaboration between healthcare professionals and patients can result in fraudulent authorization requests.
5. Misuse of Resources:
Requests for authorization for unnecessary procedures aimed at financial benefits can constitute fraud.
6. Inadequate verification:[c]
Verification failures on the part of healthcare providers can allow authorizations to be approved based on misleading information.
7. Inconsistent Internal Controls:[d]
Hospitals and clinics can face problems if they don't implement adequate internal controls to detect and prevent errors and fraud.
To avoid these situations, it is essential to invest in a robust medical bill auditing system that offers staff training, constant monitoring, support and the best of all: automated 100% auditing of hospital admission authorization processes.
Use a management of really efficient authorization
By implementing SAUDI, you can reduce up to 95% of improper or undue medical billing. In addition, the system offers numerous advantages for your healthcare provider, such as:
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- Improved technical analysis of requests with access to information in real time, which speeds up the registration and processing of authorizations;
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- Reduces the risk of improper approvals through automatic audit settings and standardized responses;
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- It facilitates the continuous improvement of the authorization process by offering access to the trail of requests and analyses;
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- It reinforces the security of decisions with real-time access to patient, provider and healthcare professional records;
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- Reduces the impact of undue charges by providers after unapproved or poorly approved services;
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- Reduces the number of bills rejected in billing;
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- Contributes to reducing healthcare costs/sinistrality;
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- And it helps to increase overall results!
Boost your company's operations with SAUDI
The SAUDI platform minimizes the likelihood of delays in responding to requests, preventing complaints from beneficiaries through more effective workflow control. This is possible by establishing specific deadlines for granting authorization or for a reasoned denial, in accordance with the rules established by the ANS.
Speed up the response time to requests by adopting online digital communication, backed up by accurate information that supports decisions in real time. This contributes to efficiency and agility in the authorization process.
Reduce the operational costs associated with the Authorization Request process by totally or partially replacing call centers, paperwork and emails, as well as the use of administrative and technical analysis by doctors and nurses. This more efficient approach brings economic benefits by eliminating redundancies and simplifying communication in the authorization flow.
Improve your results and get ready to receive compliments.
As we've shown above, SAUDI is a partner with vast experience and ready to guide your company through the digital health journey. Our team of experts is able to optimize your processes, structuring them in the most intelligent way possible according to your business's growth strategy.
SAUDI is a data-driven platform, very intuitive and simple to use. We'll surprise you within the first 3 months of using it. Contact with one of our experts right now and take your company to the next level in the digital age of health!
