GLOSAS. É POSSÍVEL EVITÁ-LA?

Fui glosado; sua glosa está alta; a glosa foi linear; não uso senão serei glosado; prepare o relatório senão haverá glosa; você vai pagar esta glosa; repasse a glosa para o médico; se atender será glosado; o convênio glosa este item, este plano glosa…

A famigerada glosa tem lugar de destaque nas nossas conversas, reuniões, cursos e etc. Mas o que é glosa? Segundo o dicionário Aurélio é uma crítica, um cancelamento ou recusa, parcial ou total, de um orçamento, carta, verba, por ilegais ou indevidos. É a diferença entre os itens e os valores cobrados e os efetivamente pagos. E quais são os motivos dessa diferença? São vários, mas para facilitar a nossa compreensão vamos dividir as glosas em quatro tipos:

I – Técnicas – São oriundas de divergências entre os procedimentos médicos adotados e os autorizados e/ou pagas. Exemplos: quantidade de sessões de fisioterapia, exames solicitados e sua indicação, tempo de permanência do paciente, medicamentos prescritos, relatórios inexistentes ou incompletos, etc.

Essas glosas podem ser resolvidas organizando-se e melhorando-se o prontuário médico e seus anexos, envolvendo enfermagem, nutrição, etc., e com o bom relacionamento entre médico assistente, diretor clínico, pré-auditoria e auditoria externa e seus representes legais.

II – Administrativas – Ocorrem em razão de falhas administrativas e/ou desconhecimento dos contratos e seus anexos, tais como validade da carteira, recibo não quitado, atendimento de especialização diferente da contratada, falta de autorização prévia, falta de extensão de contrato para outros serviços/exames, carências, serviços não cobertos, erros de cálculo, utilização inadequada de guias, falta de senhas, ausência de folhas de despesas entre outros.

Esse tipo de glosa pode ser eliminado através da melhoria dos processos, elaborações de manuais, treinamento de pessoal, informatização, controle, adequação do fluxo de informações e melhoria da comunicação interna e externa. São complicadas, mas dependem muito do nosso desempenho, motivação e capacidade gerencial.

III – Sem justificativa – decorrem da falta de caixa, desorganização ou má fé por parte de alguns poucos compradores de serviços. Exemplos: glosa linear, para ganhar tempo, por devolução total e parcial da fatura.

A resolução dessas glosas acontece através de caminhos políticos, suspensão de atendimento e exigência de justificativa junto às suas auditorias, pois geralmente esse tipo de corte não vem acompanhado de relatório que descreva as causas de tais diferenças.

IV – Por omissão – Ocorrem por omissão de contratos e tabelas acordadas entre compradores e prestadores de serviços, pois deixam margens para interpretações de lado a lado, gerando o que se chama de pontos conflitantes, tais como honorários médicos, margem e quantidade de materiais/medicamentos, intervalo entre consultas, uso de materiais descartáveis, preço de diárias e taxas, instrumentador, número de auxiliares em cirurgia, quantidade de exames, diversidade de tabelas, entre outros.

Quando observamos esses pontos separadamente, constatamos que alguns deles podem ser evitados com a parametrização dos sistemas, gestão de processos e educação permanente.

Quem sabe um dia a palavra glosa seja substituída por entendimento, parceria, participação, transparência, etc… Enquanto isso, a glosa continua

Jose Alberto Muricy

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