An efficient response to health needs is sought, guaranteeing the rights of Colombians, through a new classification of filed claims.
It is a fact that some EPS, such as Sanitas, in Popayán, are not providing an adequate service. According to patients, in the first place, it is a miracle that the operator answers to request general medicine appointments, when they get care, the doctor only limits himself to a single symptom, for another condition you have to request a new appointment. The general practitioner, if he refers to the specialist, is another odyssey for the patient, since there is almost never an “agenda”. When it is achieved, the appointment can take months, meanwhile the health of the ‘user’ is complicated. In addition, the specialist orders care from another specialist, who refers him back to the same one; that is, they send the patient from one place to another. “In Sanitas, it seems that the order was to delay and delay care,” said a patient who complained to this portal.
She also said that she sent a copy to the Health Superintendence of the right to petition sent to Sanitas Popayán, because, despite having an order for surgery, they have changed the date twice, they announce that they will call her the day before the procedure , but that EPS is not communicated with the patient.
Now, that the Supersalud announces a new policy for the management of complaints from health users, it is expected that this same entity attends to the complaints and acts for the benefit of EPS patients.
The National Health Superintendency says, in a statement sent to this media outlet, that, with the aim of guaranteeing greater efficiency in responding to the needs of users, it changed its approach to classifying and filing health claims made by citizens through the different face-to-face and non-face-to-face channels enabled throughout the country.
It adds that this new consolidated model was formalized through an external circular, through which the terms for resolving health claims are modified, taking into account the large number of specific reasons and the difficulty in differentiating between the cause and the motivation of the claim, the existing classification did not allow an adequate characterization of health claims.
“A year ago we made a promise of value and it was to turn Supersalud into an allied, friendly and supportive entity with the user, and this entails guaranteeing problem-solving capacity. Through this new methodology, we seek to restore the rights of Colombians and work for an equitable and guaranteeing health system with citizens,” said the National Health Superintendent, Ulahí Beltrán López.
the new policy
The new classification led to rethinking the maximum deadlines established to respond to requests, complaints and claims, through the definition of 37 reasons that allow the massive and expeditious evaluation of claims, taking into account the type and risk it represents for the user.
As a result, the reasons that previously exceeded 300 were reclassified into 37 specific reasons, which allows a more efficient response and in accordance with the health needs of citizens.
“The new methodology implemented will not change the access mechanisms to the Supersalud care channels established for users, nor will it generate a variation in the way they are filed. However, it is a call to attention to insurers to give priority to health claims according to the risk to which the user is exposed,” said the superintendent, Ulahí Beltrán López.
The Superintendent of Health, Ulahí Beltrán López, presented the new policy for the management of claims from health users.
From now on there will be 3 types of risk classification:
Vital risk claims with a maximum of 24 hours to resolve in depth by the guarded party. Prioritized risk claims with a 48-hour response. Simple risk claims with 72 hours for resolution.
This change will benefit users, who until now were only offered two types of risk: regular claims with 5 business days for response and life risk with 2 days.
When a denial of service is presented, the transfer will be made on a bimonthly basis to the Comptroller General of the Republic through shared access, this in order to initiate the investigations that give rise or to identify alleged fiscal findings to the detriment of the resources. public assigned to health.
“We want three types of effects: first, that a complaint be dealt with in order to generate a more timely and effective response with resolution capacity. Second, that the user can monitor what is the route and its trace; and the third, that there be an immediate attention order as soon as the claim is presented”, added the Supersalud.
Specific instructions to the EPS
The control entity urged the EPS, as those responsible for health risk management, to guarantee the provision of health services, through the establishment of a system for receiving and managing requests, complaints and claims that manages to overcome barriers. administrative measures that delay or deny access to health services.
“This reclassification makes it easier to follow up on all the claims made by users that require direct management of their EPS and they will be able to follow up on the status of their claim,” added Beltrán.
An added value for the attention of users is that from the moment we receive and classify the risk of the claim, Supersalud will issue an order to immediately comply with the monitored.
Processing of the PQR before the EPS
In accordance with the instructions given, a claim filed by a user before the EPS must be resolved within the corresponding terms, according to the type of request and must obtain the corresponding information on its status in any of the communication channels provided: telephone, web, personalized or other.
Likewise, in the cases in which the user does not indicate the means to receive the response, it must be sent to the registered email address and in case of not registering, it must be sent to his address, leaving evidence of the action.
Users of EPS Sanitas in Popayán complain about the regular care provided by that health company.
It is important to highlight that, in order to respond to the claim, the EPS may not demand from the user documents that are in their possession or in entities that make up their service provider network when applicable.
Another advantage of the new methodology is that before it was not possible to identify if the users had a medical order and now they do.
The response to the petitioner with the decision of the EPS must be dated and addressed to the informed address, the communication must be clear, complete and contain the solution or clarification of the claim and must be accompanied by a copy of the documents deemed appropriate. to support your answer.
It will be understood that there is no response, when it is issued outside the corresponding deadlines according to the type of claim and in cases where the EPS does not grant a substantive solution. In these cases, the EPS has the obligation to inform the user that, in the event of not receiving a response, it may notify the National Health Superintendency.
Terms to resolve a claim
This new methodology also provides for the report, no later than the 20th of each month, to Supersalud, of the contact details for the operation of claims marked with vital risk, and their follow-up will be in charge of the Grupo Soluciones Inmediatas en Salud attached to the Delegation for User Protection.
In accordance with the provisions of the circular, failure to comply with the instructions given will lead to the imposition of sanctions after exhausting due process.