Analyze disallowances made by a health plan operator in hospital accounts(1212 Rodrigues JARM, Cunha ICKO, Vannuchi MTO, Haddad MCFL Out-of-pocket payments in hospital bills: a challenge to management. Rev Bras Enferm [Internet]. 2018 [2019 Jul 29];71(5):2511-8. Available from: http://www.scielo.br/pdf/reben/v71n5/0034-7167-reben-71-05-2511.pdf
http://www.scielo.br/pdf/reben/v71n5/003...
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Quantitative, descriptive and cross-sectional research. Reports referring to disallowances made in eight hospitals in the operator's accredited network were analyzed, from 2013 to 2015, totaling 36 thousand items. |
The highest disallowance rates occurred in hospital 1 (67.6%); emergency room service (50.1%); length of stay ≤ 1 day (70.8%) and medical and hospital supplies (59.2%); 2013 had the highest index of administrative (54.51%) and technical disallowances (48.05%). |
Disallowances are indicators for institutions to check the critical points to be improved, requiring managers' attention to intervene in the causative aspects in order to prevent greater losses. |
Identify scientific evidence available in the literature that deals with hospital disallowances performed by the nursing audit(1313 Rodrigues JARM, Birolim MM, Cunha ICKO, Vannuchi MTO, Haddad MCFL. Hospital glosses in the nursing audit: an integrative review. Online Braz j Nurs [Internet]. 2018 [2019 Nov 19];17(1):150-60. Available from: http://www.objnursing. uff.br/index.php/nursing/article/view/5942
http://www.objnursing. uff.br/index.php/...
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Integrative review carried out in the Scientific Electronic Library Online databases; Latin American and Caribbean Health Sciences Information Literature. |
The role of the nurse auditor in the analysis of procedures and care through professional records, in reviewing disallowances and in negotiations between hospital representatives and of the agreement. The indicators responsible for the largest number of disallowances were related to nursing notes. |
The importance of complete and objective nursing records in the clients' medical records is highlighted, as it is through them that the audit controls financial costs and assesses the quality of care provided. |
Describe the experience of nurses regarding the implementation of concurrent nursing auditing in a hospital environment(66 Viana CD, Bragas LZT, Lazzari DD, Garcia CTF, Moura GMSS. Implementation of concurrent nursing audit: an experience report. Texto Contexto Enferm [Internet]. 2016 [2019 May 29];25(1):e3250014. Available from: http://www.scielo.br/pdf/tce/v25n1/0104-0707-tce-25-01-3250014.pdf
http://www.scielo.br/pdf/tce/v25n1/0104-...
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Experience report on the stages of the implementation process of concurrent audit in hospital from 2009 to 2014: elaboration of the instrument, awareness of the nursing team and operationalization. |
The nurses indicated as benefits of the concurrent audit: reduction of the time to send the invoice to the medical plans; greater interaction between auditors and assistance teams; improving care quality and nursing records. |
The nurse auditor must seek a balance between the quality of nursing care and the hospital cost. For this, you must develop / adopt processes that permeate the audit, amplifying your results. |
Map, describe and validate the auditing and billing process of accounts and disallowance resources in a general, large, private hospital(1414 Zunta R, Lima A. Processo de auditoria e faturamento de contas em hospital geral privado: um estudo de caso. Rev Eletron Enferm [Internet]. 1º de dezembro de 2017 [2019 Nov 11];190. Available from: https://www.revistas.ufg.br/fen/article/view/42082
https://www.revistas.ufg.br/fen/article/...
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Exploratory, descriptive, case study research. The mapping of the processes took place in the Internal Audit and Disallowance Sectors. The data obtained was validated by specialists in the field of audit of hospital accounts, internal and external to the hospital. |
The mapped processes - described and illustrated in the form of three flowcharts - favor professionals to rationalize activities and time spent on hospital billing, avoiding / minimizing the occurrence of failures and generating more effective financial results. |
The mapping, detailed description and validation of the auditing and billing processes and disallowance by specialists in the field of hospital accounts auditing, give greater visibility and legitimacy to the actions that are developed by the nurse auditors and provide traceability and systematic information retrieval with greater reliability. |
Check the items that comprise hospital bills, checked by nurse auditors, who receive the most adjustments at the time of the pre-analysis; identify the impact of the adjustments in the billing of the accounts analyzed by nurses and medical auditors; and identify disallowances related to items checked by the audit team(1515 Guerrer GFF, Lima AFC, Castilho V. Estudo da auditoria de contas em um hospital de ensino. Rev Bras Enferm. 2015;68(3):414-20. Available from: doi: 10.1590/0034-7167.2015680306i
https://doi.org/10.1590/0034-7167.201568...
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Quantitative, exploratory, descriptive, single case study type, in which 2,613 hospital accounts were analyzed. |
The item most included by nurses was gases (90.5%); and the most excluded, inpatient medications (41.2%). Hemodynamic materials (average R$ 1,055.90), gases (average R$ 707.91) and equipment (average R$ 689.42) were the ones that most impacted the positive adjustments. The negative adjustments resulted from improper entries in the accounts and did not generate revenue losses. The items that significantly influenced the disallowances were the equipment, followed by hospital gas and medication. In the accounts audited by doctors, it was not possible to itemize the items due to the absence of this record. |
The study provides data for the advancement of knowledge of hospital accounts auditing as it investigated the pre-analysis process carried out by a team of auditors consisting of nurses and doctors. |
Estimate the disallowance rate on materials and medicines in a private hospital in the Federal District(11 Oliveira AD, Costa CR, Arndt ABM. Glosas de materiais e medicamentos em um hospital privado na cidade de Brasília, Distrito Federal. Acta Cienc Saude [Internet]. 2012 [2019 May 21];2(1). Available from: http://www2.ls.edu.br/actacs/index.php/ACTA/article/view/39/46
http://www2.ls.edu.br/actacs/index.php/A...
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Quantitative, retrospective, descriptive study. Data collection took place in the billing sector, based on disallowance reports and semi-structured questionnaire applied to members of the sector. |
Materials have a higher level of disallowance than drugs (65%), and the impact of total disallowances in the institution represented approximately 10% of the billing of all services. |
Disallowances may be reduced with the adoption of service protocols by health professionals involved in the assistance process, providing cost reduction and rational use of material and medicines. |
Develop chemotherapy medication consultation application for web system and mobile device in order to assist in nursing audit of hospital accounts and assess user satisfaction and usability(1616 Grossi LM, Pisa IT, Marin HF. Oncoaudit: development and evaluation of an application for nurse auditors. Acta Paul Enferm [Internet]. 2014 [2019 Nov 11];27(2):179-85. Available from: http://www.scielo.br/pdf/ape/v27n2/en_0103-2100-ape-27-02-0179.pdf
http://www.scielo.br/pdf/ape/v27n2/en_01...
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Applied research of technological production aimed at developing an application in a web environment and mobile technology for consultation of chemotherapeutic drugs in the audit of hospital accounts. The product was evaluated for satisfaction by nurse auditors using the System Usability Scale questionnaire and for usability by Nielsen's heuristics, by health informatics professionals. |
Five nurse auditors evaluated the application on the tablet and five on the web system. The evaluation with the System Usability Scale questionnaire showed that the average value was 90 ± 5 for the application on the tablet and 97 ± 5 on the web system. Nurses found the application on the tablet easy to use, useful, innovative, complete and with important information to audit accounts of antineoplastic drugs.
In the usability assessment, 14 problems were identified in the mobile application and eight in the web system, generating changes in both. |
The methods chosen for development and evaluation proved to be satisfactory to achieve the proposed objectives.
Although with limitations due to the small number of evaluators, it was demonstrated that the application can be used in the practice of medication auditing, making it more agile and complete. It may also achieve greater repercussions with the incorporation of more pharmacological groups. |
Raise the reasons for disallowed invoices, forwarded to the Commission of Lisura of a military hospital in the central region of the state of Rio Grande do Sul(1717 Lana LD, Ferrazza CAC, Quadros JN, Birrer JA. Auditoria em organizações prestadoras de serviço: uma estratégia de gestão econômica. Rev Adm Saúde [Internet]. 2012 [2019 Nov 11];14(56):103-8. Available from: https://cqh.org.br/portal/pag/anexos/baixar.php?p_ndoc=420&p_nanexo=343
https://cqh.org.br/portal/pag/anexos/bai...
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Quantitative, exploratory and descriptive study. The sample consisted of invoices belonging to a specific health insurance plan sent to the Commission of Lisura of a military hospital from January to June 2007. |
It was shown that 90% of invoices had inadequate and / or incomplete filling; 30% had the charged medication (s) that did not match the medical prescription, and 40% had no medical progress on the visits charged. |
It was found that 52.2% of the audited medical records had information flaws that could result in total or partial disallowance. The need to adopt new training methodologies for professionals to internalize their role in health auditing has been proven. |
Check in the national literature the importance and intervening factors in nursing notes in relation to hospital disallowances(1818 Prado PR, Assis WALM. A importância das anotações de enfermagem nas glosas hospitalares. CuidArte Enferm [Internet]. 2011 [2019 Jul 14];5(1):62-8. Available from: http://www.fundacaopadrealbino.org.br/facfipa/ner/pdf/CuidArte%20Enfermagem%20v.%205%20n.%201%20jan.jun.%202011.pdf
http://www.fundacaopadrealbino.org.br/fa...
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Literature review with articles published between 2000 and 2010, in national scientific journals available in the Virtual Health Library, Scientific Electronic Library Online, Latin American and Caribbean Literature in Health Sciences and non-systematized sources. |
Twelve articles showed flaws in the nursing notes: illegible handwriting, erasures, inaccuracies regarding the time of the annotation, identification of the professional, checking of medicines, discrimination of materials and annotation of the procedures and the failure to implement the Nursing Care Systematization. |
It is suggested the role of the nurse auditor in supporting continuing education teams and the use of Nursing Care Systematization for better qualification of nursing care, in addition to reducing the number of disallowances in hospital institutions. |
Identify the impact caused by the non-registration of nursing as opposed to any disallowances, highlighting the main types resulting from these records(1919 Ferreira TS, Souza-Braga AL, Cavalcanti-Valente GS, Souza DF, Carvalho-Alves EM. Auditoria de enfermagem: o impacto das anotações de enfermagem no contexto das glosas hospitalares. Aquichan [Internet]. 2009 [2019 Sep 12];9(1):38-49. Available from: http://www.scielo.org.co/pdf/aqui/v9n1/v9n1a04.pdf
http://www.scielo.org.co/pdf/aqui/v9n1/v...
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Descriptive and exploratory research, with a qualitative and quantitative approach, carried out in the urology service of a private hospital in the city of Niterói / Rio de Janeiro. |
4,380 items were disallowed, highlighting, with greater need, the following records: medications (R$ 8,551.07; 53.16%); oxygen (R$ 1,936.96; 79.51%); dressing (R$ 1,008.52; 41.40%); nebulization (R$ 644.08; 26.44%); gauze pad (R$ 1,001.12; 44.55%), procedure glove (R$ 869.62; 38.70%) and lab coat (R$ 656.76; 29.22%). |
It is emphasized that nurses need to assess the quality of the records of nursing professionals under their responsibility and plan educational activities (systematic training) to improve the training of these professionals in the face of the flaws / inconsistencies found. |
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