This document discusses the challenges of knowledge transfer for medical auditors in Brazil's private healthcare system. It finds that medical auditors must handle a large volume of complex issues and authorization requests within limited timeframes. They often lack knowledge of evidence-based practices and coverage policies can vary between companies. To address these challenges, the document recommends producing more concise guidelines, improving communication strategies, and increasing motivation for guideline use through workshops and discussions. A survey of medical auditors found they use technical advice in practice but communication and formatting of advice could be improved.

1. THE MAXIMUM OF INFORMATION IN A MINIMUM OF WORDS
Knowledge Transfer Challenges in Supplementary Health Care System
Isabella V. de Oliveira, MD, MSc
BRC Healthcare Solutions, Brazil
ABSTRACT
In the last years, many initiatives published by the Ministry of health, National Agency of Sanitary Surveillance (Agencia
Nacional de Vigilância Sanitária - ANVISA) and National Regulatory Agency for Private Health Insurance and Plans
(Agencia Nacional de Saude Suplementar – ANS) met the gap between clinical research and decision makers in Brazil.
However, in the micro environment of a private Health Care company, we need to reprocess these studies, adapting
them to the needs and realities of professionals working at the end of the authorization and health technology
incorporation processes. This article aims to evaluate the needs of HTA users and to describe the challenges of
knowledge transfer for medical auditors in the private health care environment.
METHODS
Descriptive analysis of requests from medical auditors received by the Technical Areas at two self insured private
health care companies filed in the period 2013 to 2014 and a cross-sectional study of a convenience sample with ten
medical auditors.
RESULTS
In the process of KT, the stakeholders are the medical auditors (who receive and analyse the claims) and the Technical
Regulation Department (decision makers which produce coverage guidelines and disseminate knowledge to the
auditors). The medical auditors work with a significant load of issues, given the multidisciplinarity of their performance.
On the same day, they handle with simple matters, even far more complex issues, such as a claim for a neurosurgery
with special high cost devices. The diversity of affairs is huge, as well as the amount of incorporation requests they deal
with. In addition, the medical auditors are obliged to deal with a limited term, since an authorization shall be issued in
up 24 hours. This scenario virtually obliges them to have prompt answers.
One more fragility to be considered is the lack of knowledge on Evidence-based Practices. It reaches both phycisians:
prescribers and medical auditors. Many prescribers still rely on studies of notable absence of robustness of evidence
and in his personal experiences (the famous "How I Treat"). Surprisingly, many physicians do not speak English and
culturally there is a remarkable resistance to read very large documents. Another challenge to be overcome is that the
medical auditor may work in two or more companies, and the companies may have different coverage policies. It
increases the likelihood of human errors at the time of authorization, in the absence of reminders or other type of alert
entered into the computerized system.
Table 1: Some of the new health technologies demanded between 2013-2014 on two self insured companies (total
433,568 beneficiaries).
The key questions that the auditor must make upon a receipt of request from a new health technology (HT) are:
1) Is the HT effective ?
2) Is the HT safe?
3) Is the HT approved by ANVISA and by Federal Medical Council?
4) Is the HT included in any official procedure table (CBHPM or other)?
5) Is the HT mandatorily covered according to ANS?
6) If the answer to question 5 is positive, in which code?
7) If the answer to question 5 is negative, which denial reason should I use?
RESULTS CONTINUED

2. THE MAXIMUM OF INFORMATION IN A MINIMUM OF WORDS
Knowledge Transfer Challenges in Supplementary Health Care System
Isabella V. de Oliveira, MD, MSc
BRC Healthcare Solutions, Brazil
RESULTS CONTINUED
Table 2: Questionnaire to assess knowledge, satisfaction, perception and use of technical advice
CONCLUSIONS
REFERENCES
One hundred% of the respondents said they use the opinions in practice and that they standardize the conducts in the
team, which is good. However, there's a failure in the communication strategy of the opinions (20% have partial
knowledge of opinions). Currently the opinions are published in a monthly basis and entered into a shared folder
among medical auditors. The publication is informed via e-mail.
There is a need for greater motivation about the use of guidelines (20% agree partially that feel motivated). This could
be achieved with the introduction of monthly meetings and workshops for discussion of published opinions and
exchange of experiences between colleagues (as was even the suggestion of one of them). The guidelines format will
be improved with the inclusion of the key questions.
The coverage information must be clear at the end of the document. The possibilities of using analogy of codes by the
requesting physician must be highlighted in order to avoid unwanted incorporation of some technology not covered.
The justifications for denial must be standardized to facilitate communication with the requesting physician and the
argumentation to be used at the time of contact. Such justifications are also invaluable in technical advice to support
the Legal Defense of a lawsuit, or when you need to respond some Notification of Preliminary Intermediation from
ANS.
It becomes imperative to elaborate more concise documents, containing a maximum of information in a minimum of
words. The main challenges in transferring knowledge to medical auditors in a healthcare private company are: delivery
time and conciseness of the document.
In a convenience sample with 10 medical auditors we applied a questionnaire to assess knowledge, satisfaction,
perception and use of technical advice (adapted from HCPA experience: Assistance Protocols as adherence strategy to
the best clinical practices and resource optimization) – Table 2.
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