Assisted reimbursement in healthcare refers to a process in which healthcare professionals or institutions have specialized support to facilitate requesting and obtaining reimbursement for services provided. This support may include help with preparing documentation, checking compliance with rules and regulations, and guidance during the reimbursement claim submission process. The objective is to optimize the process, reduce errors and ensure efficient and accurate reimbursement.

This approach aims to minimize errors, reduce processing time and maximize financial reimbursements. To the adopt assisted repayment, healthcare professionals can focus more on patient care, while specialists deal with administrative complexities, improving operational efficiency and ensuring more effective financial management.

 Fraud in refund requests

Health plans, which have been suffering from financial losses since last year, say that fraud in reimbursement requests is one of the elements that most impacts the sector. According to a survey by the National Supplementary Health Federation (FenaSaúde), between 2020 and 2022, healthcare operators' expenses with reimbursements increased by more than 90% in the same period. According to the entity, the cheats they can compromise the service of the agreements, which have already accumulated losses estimated at more than R$10 billion.

Fraud in assisted reimbursement claims in healthcare can occur in several ways, often exploiting gaps in the operation or manipulating information. Here are some common strategies used by fraudsters:

1.False Documentation:

Submitting falsified documents, such as receipts, medical reports, or treatment information, in an attempt to receive improper reimbursements.

2.Services Not Provided:

Requesting reimbursement for medical services that were never actually provided, resulting in the difficulty of effective verification.

3. Erroneous Coding:

Manipulation of procedure or diagnosis codes to inflate costs and increase the amount requested in the reimbursement request.

4.Improper Use of Identity:

Using false identities or real patient information to submit fraudulent claims.

5.Collusion between Healthcare Professionals:

Collaboration between healthcare professionals and patients to submit reimbursement requests for services not performed or unnecessary.

6.Double Billing:

Submitting reimbursement requests for the same service to different insurers, seeking to receive more than the actual cost of the treatment.

7. Electronic Data Handling:

Alteration of electronic records to present conditions that are more serious than actual conditions, increasing the amount of reimbursement requested.

8. Reimbursement for Non-Prescription Medications:

Requesting reimbursement for medicines that were not prescribed or purchased, often exploiting electronic prescription systems.

Preventing fraud in assisted reimbursement claims requires robust verification systems, continuous monitoring, rigorous auditing procedures and the use of advanced technologies, such as data analysis and artificial intelligence, to identify suspicious patterns. Education and training of healthcare professionals also plays a vital role in preventing these fraudulent practices.

In addition to fraud, there are cases of misuse and waste:

• Lack of coverage;

• Lack of relevance technique for carrying out the procedure doctor;

• Consumption of procedures, daily allowances, materials and medicines beyond what is necessary;

• Prices above those charged by the market.

 

How does SAUDI work in the assisted reimbursement process?

Having a data-centric platform can be crucial to improving the assisted reimbursement process, generating significant positive impacts. Check out the benefits that SAUDI provides for healthcare providers below: 

1. Precise Data Analysis: The platform can analyze financial and clinical data to ensure that the information presented in reimbursement requests is accurate and complete, reducing errors, fraud risks and increasing the chances of approval.

2. Process Automation: Automating administrative tasks related to reimbursement, such as filling out forms and checking compliance, streamlines the process, saving healthcare professionals time and improving efficiency.

3. Compliance Monitoring: The platform can continuously monitor changes in reimbursement rules and regulations, ensuring requests are always compliant, reducing the risk of denials.

4. Integration of Clinical and Financial Data: Uniting clinical and financial data allows for a holistic view, making it easier to identify patterns, predict reimbursements and optimize strategies to improve financial results.

5. Analytical Reports: Provide detailed reports and analysis on financial performance, reimbursement rates and areas for potential improvement, enabling more informed and strategic management.

6. Real-Time Updates: The platform can offer real-time updates on the status of refund requests, allowing a quick response to any problems and streamlining cash flow.

See how SAUDI shields your healthcare provider

By hiring SAUDI, there will not only be an optimization of processes, but also an increase in the quality of information, promoting efficiency, compliance and better financial management for your healthcare institution. 

The largest healthcare providers in Brazil are already investing in technology to protect themselves. They use the Medical Bill Audit most awarded in the country, the SAUDI. 

With this data-driven, modular and fully customizable platform, they ensure the integrity of all processes, always following market developments and updates to sector regulations.

Request a demo of SAUDI and understand how the system preferred by medical account managers can improve assisted reimbursement, shielding the largest healthcare providers in Brazil against various types of scams and fraud