A contribuição potencial do Biomédico Auditor na identificação e redução de glosas em Operadoras de Planos de Saúde

Resumo (EN)

Objective – This study aimed to analyze the most recurrent types of claim denials applied by health plan operators and investigate the potential of the biomedical auditor in mitigating these non-conformities. Methods – This is a qualitative, exploratory, and descriptive research study, based on documentary analysis of public data made available by the ANS and the Anahp Observatory Report, complemented by a literature review on auditing in supplementary health care and the role of the biomedical professional, as foreseen in the National Curriculum Guidelines and Resolution No. 184 of the Regional Council of Biomedicine (CRBM). Results – The documents allowed the identification of the main reasons for claim denials, highlighting the need for standardized processes and careful analyses. Conclusion – Based on the technical-scientific competencies foreseen in the National Curriculum Guidelines and Resolution No. 184 of the Regional Council of Biomedicine (CRBM), the biomedical auditor demonstrates the potential to issue and interpret reports, resolve doubts, harmonize procedures, and audit patient progress, contributing to the reduction of undue claim denials and optimization of processes.