The entry into force of decrees 170/2024, 171/2024 and 172/2024, with which the national government advanced in the regulations of DNU 70/23, in addition to promoting free competition between social works and prepaid, giving people freedom of choice, foresees a transformation of the contracting model.
In this context, technology provides solutions to resolve complexities linked to the management of the provider network.
In particular, Decree 172/2024 on Health Insurance Agents establishes that both health service providers and public hospitals may establish agreements directly with social and prepaid works or through a local authority.
Specifically, in its article 1, the norm establishes that “the Health Insurance Agents included in Laws Nos. 23,660 and 23,661 and their respective amendments may enter into agreements with the providers of the public subsystem, aimed at establishing the mechanism to implement the payment of benefits, either through the corresponding jurisdictional authority or individually.
Then, in article 2, the regulations specify that “for the celebration of the agreements mentioned in article 1“, the effectors of the public subsystem must be registered in the Federal Registry of Health Establishments (REFES) or in the one that replaces it in the future.”
While article 3 of the decree provides that “the agreements referred to in articles 1 and 2 hereof will be a free agreement between the parties and may establish, among other guidelines, the type of practices included, its coding, values, billing rules and methods of payment and dispute resolution.”
Challenges for the contracting system
The different actors in the health ecosystem require contractual agreements to manage the network of providers, provide effective care, and have fluidity in allocating resources.
The assembly of the provider network by a health insurer, Whether it is a social work or a prepaid one, it is complex. And the challenges have to do with the continuous negotiation of contracts due to economic, regulatory, technology inclusion, or new needs factors.
All this negotiation and updating is based on physical contracts, meetings, phone calls and dozens of emails between the insurer and the providers. Therefore, the comprehensive and strategic perspective for monitoring and measuring the network of providers is usually lost, and the same occurs with the control of the quality of the service provided to the beneficiaries.
Good contracting of providers is based on planning demand and the quality of care that members receive. All this, taking into account the costs and subsequent medical bills (billing and payment).
As of the entry into force of Decree 172/2024, health insurers must contract public hospitals and identify the services they need, negotiating prices with each director.
These contracts are going to be very difficult to generate and control if there is not a tool that helps manage all the services and prices agreed upon with each provider.
Technology to achieve efficient hiring of health providers
Faced with the contracting model promoted by decree 172/2024social and prepaid works will need to deepen the digitalization and systematization of their management, based on knowledge of the network of providers, the supply and demand of health services in each market.
A process that, without the support of technology, would be extremely complicated to solve in an agile and efficient way.
In response to these needs, our Contracting Module helps social and prepaid works to generate clear policies for contracting and evaluating providers, with the aim of optimizing user service. In addition, it allows the construction, traceability and monitoring of contractual agreements with the different providers.
Although prepaid companies, in general, already have a hiring module incorporated, many social works managed by guilds and unions have yet to take the step to implement it and be able to be on equal terms with their now competitors, in relation to a highly sensitive for management.
CEO of Conexia
Source: Ambito
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