The influence of records on medical charts as a factor associated with technical disallowances

Objective: identify the influence of records in medical charts as one of the factors associated with technical disallowances. Method: quantitative, analytical, cross sectional field study conducted in 2018 in two hospitals. A total of 324 payment statements were analyzed, considering five health pla...

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Detalles Bibliográficos
Autores: Truzzi, Ingrid Gomes de Campos, Jericó, Marli Carvalho, Lima, Antônio Fernandes Costa, Zunta, Raquel Silva Bicalho, Oliveira, Débora Soares de, Romcy, Helena Maria
Tipo de recurso: artículo
Estado:Versión publicada
Fecha de publicación:2022
País:Brasil
Institución:Universidade Federal de Minas Gerais (UFMG)
Repositorio:Reme (Online)
Idioma:portugués
inglés
OAI Identifier:oai:periodicos.ufmg.br:article/39425
Acceso en línea:https://periodicos.ufmg.br/index.php/reme/article/view/39425
Access Level:acceso abierto
Palabra clave:Registros Eletrônicos de Saúde
Faturamento
Saúde Suplementar
Gestão em Saúde
Electronic Health Records
Billing
Supplemental Health
Health Management
Registros Electrónicos de Salud
Facturación
Salud Complementaria
Manejo de la salud
Descripción
Sumario:Objective: identify the influence of records in medical charts as one of the factors associated with technical disallowances. Method: quantitative, analytical, cross sectional field study conducted in 2018 in two hospitals. A total of 324 payment statements were analyzed, considering five health plan operators in each hospital. These statements contain the codes of disallowances provided in the TISS [Exchange of Information on Supplementary Health] Table. Results: technical disallowances concerning materials were higher than those concerning medications in hospitals 1 and 2, 90.99% and 84.79%, respectively. The factors associated with technical disallowances were hospital stay — p=0.001 in hospital 1 and p=0.01 in hospital 2 — and type of hospitalization in hospital 2, p=0.000. Hospital 1 amounted to R$2,305.61 (2.28%) of disallowances in nine medical charts. However, all the medical charts contained the records of technical reports, which can be appealed. A different result was found for hospital 2, where 43 medical charts totaled R$31,181.14 (17.82%) of disallowances, R$3,096.13 of which concern missing codes (material and medication); hence, no appeal is possible, resulting in financial loss. Conclusion: the monetary amounts of technical disallowances were higher in both hospitals. There is evidence that the length of hospital stay generates disallowances. Therefore, the records in medical charts influence disallowances, and missing records lead to financial loss. TISS standardizes the reasons for disallowances, favoring justifications to appeal, and facilitates the analysis of records and controls of payments to the services provided.