Auditoria médica e custos assistenciais em uma cooperativa médica: um estudo sob a perspectiva de médicos auditores

Abstract

Health audit plays an essential role in monitoring and surveillance with the use of medical assistance services. In this context, health care costs are a central concern of healthcare operators in Brazil, especially after the adoption of the regulatory framework through Law 9656/1998 and, soon after, the creation of the National Suplementary Health Agency- NHS (Agência Nacional de Saúde - ANS), in January 2000. The inclusion of several obligations in the service to users requires from these operators an economic-financial readjustment, aiming at sustainability in the healthcare market. The audit has a strategic effect in maintaining sustainability with quality service. This work deals with the perception of the auditors of Unimed Fortaleza about the relationship between healthcare costs and auditing within the scope of their performance, being a case study of a qualitative nature and descriptive character, carried out through documentary and field research. The production of the data took place from the documentary study and the semi-structured interview, treated with the use of the qualitative data analysis software Atlas Ti and analyzed according to the elements of Laurence Bardin's Content Analysis. The research pointed to a particular perception of the activities of the auditors, who seek to comply with norms and regulations of procedures in order to establish a culture of prevention of surplus of healthcare costs, continuous and permanent training of members and collaborators to reduce losses and strengthen belonging to the cooperative identity. The work demonstrates the importance of good corporate communication and the need to invest in these processes. Technologies are understood as allies in the development of the flow of processes and requests, as well as in the creation of means and mechanisms for improving health in general, and in this field they are also seen as elements of pressure on healthcare costs as they generate requests outside the covers. In view of the action for compliance between health care with quality and balance of care costs, it was concluded that this is still a field to be explored within the scope of the cooperative, giving rise to more specific later studies on the fields of performance of the audit.