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Importance of reconciling TISS standard payment statements and disallowances

Prior to the TISS (Supplementary Health Information Exchange) standard, it was very difficult and financially unviable to reconcile exam-to-exam payment statements and disallowances. Beginning with the simple fact that many operators did not give this type of information or, when they sent, the information was not complete, thus making reconciliation impossible without any level of interpretation or risk of wrong attendance.

All this seems very innocent and bureaucratic, but when we look at the issue coldly, we realize that clinics don't get 100% or anything close to what they do for exams.

Tabela - TISS

In the table, it is clear that there are several stages in which losses can happen and that if there is not a well designed and implemented process to ensure the traceability of the exams made, we will lose this money at some point without realizing it.

For many years, we have heard from clinics across Brazil that there are very low or nonexistent gloss values, but managers forget that we are not just talking about the gloss that comes from a statement received from operators. We have several process steps that can lead to losses even before billing reaches the healthcare provider.

We are faced with a situation that has clearly shown this. We had high accounts receivable balances with one carrier and when we charged them we were told that there was no balance to pay on her system that we were wrong and asked us to prove guide to guide, exam to exam, that she owed it to the clinic. She knew we did not have this control because this carrier's statements were nonstandard and made available as a PDF file.

As we were big, we were able to get the statements from the previous two years and reconcile everything. The fact is that we were able to recover a lot of money and the response we received from the healthcare provider was that the guides were not processed and should have been lost in the process.

After that, we began to look at all the operators and realized that the fact was repeated. With this, we understood the need to reconcile 100% of the exams, but we also understood that doing this manually was unfeasible financially due to the number of employees we should have in the responsible sector.

The TISS 3.02 standard, in its latest version, requires health care providers to send providers XML statements, thus enabling automated reconciliation and ensuring that the clinic will know which tests are performed and how much is received.

The health care providers' resistance to making these files available has been strong because these unprocessed guides ultimately benefit them. When we talked about this at the meeting of the Supplementary Health Information Standardization Committee (COPISS) of the National Supplementary Health Agency (ANS), the operators argued that they have offered providers the XML statements, but few have requested them.

Therefore, we recommend that you request your statements and update your clinic's RIS systems for this process to be automated. In the case of health operators who deny or deliver non-standard, report them to ANS. They should have started sending the statements since August 31, 2014 in version 03.02, which already brings the improvements mentioned.

It is worth remembering that ANS, in a meeting of the Technical Group of Law 13.003 / 14 held on February 15, displayed the information that from January 2015 to September 2016 were spent R $ 11.3 billion in disallowances, 6 , 69% of all that was attended in the Supplementary Health in Brazil in the period.

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Thiago Braga

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