Decree 441: voluntary agreements between EPS and IPS
Francisco Jose Garcia Lara
Surgeon and Master in Health Administration
from the Javeriana University
Columnist of the newspaper La Nación de Neiva
In any health system, the relationships between the actors are essential, and for the proper functioning of this, the agreements of wills between the insurance company (EPS or similar) and the health service providers (IPS) and the providers of technologies are essential. in health.
To regulate the agreements of wills, the national government issued Decree 441 of 2022, of which we present the most relevant aspects below.
Although it is possible that there are several previous regulations, Decree 4747 of 2007 expressly established the reference framework for agreements of wills between EPS and IPS.
As a result of the issuance of Decree 780 of 2016, in which the regulations of the health sector were compiled, Decree 4747 was incorporated into its Chapter 4 of Title 3 of Part 5 of Book 2.
It is precisely that part of Decree 780, which is replaced in its entirety by Decree 441 of 2022.
The main justification for the issuance of decree 441 is the need to establish minimum elements of the agreements of wills to guarantee the access of Colombians to the health system, as can be deduced from the consideration part of the aforementioned administrative act.
In addition to the above, in summary, the justifications for issuing the decree are as follows:
- Market failures related to information asymmetries.
- Mistrust between the actors of the system.
- Outdated payment methods.
- Guarantee comprehensive care for patients with high-cost diseases.
- Define clear rules when there is a change of provider or provider, including continuity of care for EPS affiliates that are liquidated.
- Have measurable and quantifiable variables for the follow-up and monitoring of agreements of wills.
- Establish auditing elements in the accounts presented by the IPS and technology providers to the EPS.
- Include the new general billing rules and their adaptation in the health sector.
- Avoid delaying actions that delay the flow of resources.
- Need to update the values when the agreements of wills are extended over time.
The main changes
Taking into account the drawbacks identified and mentioned in the previous point, broadly speaking, the main adjustments included in the decree are the following:
- It establishes the elements for the negotiation of the agreements of wills for the EPS, the IPS and the health technology providers, as well as the common elements. Among others: care model, characterization of the population, list of offices and installed capacity.
- Defines the minimum content that the agreements must have, for example: object, duration, place, rates, technical note, integral network, payment method, coordination of the reference and counter-reference process, agreed indicators.
- It includes indicators of structure, process and result, in such a way that the quality of care, management and health results are measurable.
- For the quality of service attention, it reiterates that it will be developed in accordance with the Audit Program for Quality Improvement – PAMEC; and that of medical bills, in accordance with the Single Manual of Returns, Glosas and Answers issued by the Ministry of Health.
- It obliges to include in the agreement of wills the periodic monitoring and evaluation of the technical note.
- It defines that the EPS must be given access to the clinical history, digitally or electronically, in order to carry out the required verifications.
- Regarding billing, it reiterates that the supports are those defined by the Ministry of Health, specifying that the Individual Registry for the Provision of Health Services (RIPS) is a mandatory support.
- The acceptance of glosses and invoices must be processed in accordance with the provisions of article 57 of Law 1438 of 2011.
- For providers of health technologies, it allows the application of what is defined in the aforementioned article or the norms established in the commercial code or tax statute.
- In the payments, it must be informed within the three days following the draft to which the invoice corresponds. In the same way, it specifies what is related to reimbursement of payments for non-compliance and returns and discounts.
- It requires that the increases in values be included in the agreements when automatic extensions are agreed. When these are not expressly established, the criteria defined in article 220.127.116.11.3 of decree 780 will be applied.
- Authorizations for comprehensive care for childhood cancer, HIV/AIDS, adult cancer and all those that the Ministry of Health or the EPS themselves define as priority are eliminated.
- In the event of a change of service provider due to termination of agreements of wills or liquidation of the EPS, it establishes the procedure to guarantee comprehensive care for patients.
- The mechanisms and deadlines for the delivery and updating of the information must be included in the agreements of wills.
It is important to point out that the decree brings many more provisions, several of them included in previous regulations, for which these do not represent any change in relation to decree 4747.
Finally, the implementation of the provisions provided for in the decree will be on May 1, 2022 for new agreements and on July 1 for those that are in progress.
It will work?
Having reviewed the consideration part of the decree, it is possible to affirm that the diagnosis is adequate. Consequently, the elements and guidelines included in the decree seem to resolve the inconveniences that have been arising between insurers and providers.
At the same time, it is insisted, the decree contains rules that exist, such as default interest for late payment.
On the other hand, it is questionable that the government regulates agreements of wills that are decisions between private parties, even though they involve public resources. The dominant position of the EPS is a reality, but it is also true that there are general rules on the abuse of this position, which have been applied in the past, therefore, they do not require additional regulation.
In any case, it is essential to bear in mind that any agreement, regulated or not, will only be fulfilled by the will of the parties, that is, it does not depend on a norm, but on the decision of each party to do what it promised.
The government's effort in issuing the decree continues to be significant and important, which should be accompanied by a commitment to apply the corresponding measures in the event that any actor in the health system fails to comply with the regulations, forcing him to adjust to them, without prejudice to the sanctions that may apply.
In conclusion, the mere fact of the existence of a regulatory standard does not solve the inconveniences or guarantee per se that what is established therein is complied with, and if the severe deficiencies of the inspection, surveillance and control system are not corrected, these types of efforts are the risk of remaining a dead letter.
Other blogs readers viewed
1. Pages 1 to 5 of Decree 441 of 2022
2. Applies to agreements with prospective payments, in order to establish the adjustments required for changes during their execution. For greater clarity, it is recommended to read the definition on page 6 of the decree.