Impacto financiero de la gestión de glosas y devoluciones en una Institución prestadora de servicios de salud de tercer nivel de complejidad en la ciudad de Bogotá D.C.

Abstract

The management control system enables Healthcare Service Providers to conduct a comprehensive evaluation of their institution, comparing expected versus actual results. It is necessary to continuously evaluate institutional processes to generate a Quality Improvement Plan and systematic verification mechanisms for medical, accounting, financial, and operational audits. These audits directly impact the institution's resource flow. Timely management of objections reported by Companies Responsible for Payment is a crucial strategy for ensuring institutional solvency and liquidity. Failure to comply with established timelines for objection responses affects the institution's operations as it may delay timely payment for medical services rendered. This document proposes an analysis of medical account auditing management of a third-level Healthcare Service Provider in Bogotá D.C. using a quantitative descriptive methodology. It aims to evaluate the financial impact of managing objections and returns of invoices filed before different Benefit Plan Administrative Entities contracted to provide medical services. The study also identifies the causes leading to the results found and provides recommendations to strengthen the institution's structure, process, and results to mitigate solvency and liquidity risks. Decree 4747 of 2007 and Resolution 3047 of 2008, modified by Resolution 416 of 2009, assign responsibilities for healthcare service providers and Companies Responsible for Payment. They aim to ensure proper administration of payment mechanisms for health services purchases and establish requirements for invoicing and objection management timelines. In this study, billing procedure and medical account and portfolio audits revealed weaknesses, reflecting a high portfolio volume to collect, slow cash flow, and sustained increases in objections and returns. The institution's document management for billing, portfolio, and audit processes requires updating and adjustments. The institution must implement cost measurement and control mechanisms per functional unit to make decisions related to medical cost management without affecting service quality. Although there are defined management and control indicators, they are not rigorously evaluated daily, making it challenging to monitor and control financial risk. The institution must implement mechanisms to settle and bill services promptly, clearly, and comprehensively to facilitate rescue and guarantee income for survival, growth, and development