Importance of the TISS Standard for Radiology and Diagnostic Imaging clinics
The TISS Standard (Exchange of Information on Supplementary Health) of the National Supplementary Health Agency (ANS) has completed more than ten years, but it is worth recalling some very important points, which many operators have not followed, but which are fundamental to the clinics. In the first versions of the TISS 1.0 and 2.0 standards, the clinics only suffered negative impacts, they had to adapt their care and billing systems, an increase in the amount of information in the guides, reflecting in the increase in the number of employees in the respective areas and mainly the increase in gloss values, because the validation tool of the XML files of the standard served to automate the process of glosses by health insurance companies. In the TISS 3.0 version, clinics begin to have some important opportunities to reduce the costs of patient eligibility processes, authorization of exams, reconciliation of payments and reconciliation and recourse of disallowances. According to the table below, operators should have already implemented the first version 03.02 since August 31, 2014, which already brings the aforementioned improvements.
It is essential to understand that the motivation and gain from implementing these improvements is only valid for clinics, because when there is a mistake in the eligibility of patients and/or in the authorization of tests, it is glossed over, while the patient of the health insurance company was attended to and will receive his exam. In the case of conciliation, it is only possible to be sure that we receive 100% of what we provide if we are able to reconcile exam by exam, patient by patient. In the past, due to the lack of standards in the statements, it was practically impossible to automate the reconciliation, and to do it manually, the cost of personnel was greater than the possible loss, or we all thought so.
In a meeting of the Technical Group for Law 13,003/14, which took place on the 15th of February, the ANS showed the table below showing what we all felt, but we were not sure of the size! From January 2015 to September 2016 there were R$ 11.3 billion in disallowances, 6.69% of all that was attended to in Supplementary Health in Brazil in this period. Likewise, it is worth remembering that within the TISS standard there is the TUSS (Unified Terminology of Supplementary Health), which objectively determines and expresses the codes and nomenclature of the procedures that operators must follow. The TISS Standard, in its current version, is an obligation for health insurance companies that are governed by the ANS, it is not optional. Below is the link to the current version of the current TISS standard.
http://ans.gov.br/prestadores/tiss-troca-de-informacao-de-saude-suplementar
Carlos Moura Economic Advisor at CBR
It is essential to understand that the motivation and gain from implementing these improvements is only valid for clinics, because when there is a mistake in the eligibility of patients and/or in the authorization of tests, it is glossed over, while the patient of the health insurance company was attended to and will receive his exam. In the case of conciliation, it is only possible to be sure that we receive 100% of what we provide if we are able to reconcile exam by exam, patient by patient. In the past, due to the lack of standards in the statements, it was practically impossible to automate the reconciliation, and to do it manually, the cost of personnel was greater than the possible loss, or we all thought so.
In a meeting of the Technical Group for Law 13,003/14, which took place on the 15th of February, the ANS showed the table below showing what we all felt, but we were not sure of the size! From January 2015 to September 2016 there were R$ 11.3 billion in disallowances, 6.69% of all that was attended to in Supplementary Health in Brazil in this period. Likewise, it is worth remembering that within the TISS standard there is the TUSS (Unified Terminology of Supplementary Health), which objectively determines and expresses the codes and nomenclature of the procedures that operators must follow. The TISS Standard, in its current version, is an obligation for health insurance companies that are governed by the ANS, it is not optional. Below is the link to the current version of the current TISS standard.
http://ans.gov.br/prestadores/tiss-troca-de-informacao-de-saude-suplementar
Carlos Moura Economic Advisor at CBR