Objective:

To characterize reimbursements claimed by the Departmental Health and Social Protection Secretariat of Antioquia (SSSPSA) and submitted to the Solidarity and Guarantee Fund for non-POS interventions [services not covered by the Compulsory Health Plan] between 2010 and 2013.

Methodology:

A retrospective descriptive study was performed based on official information provided by the SSSPSA considering the total of reimbursed claims (894) corresponding to 7,815,241,869 COP.

Results:

1) Reimbursed claims decreased from 56 to 9%, with a negative variance of -84 %; reimbursed items decreased from 51 to 15%, with a negative variance of -71 %, and patients involved had a negative variance of -79 %; 2) accepted claims decreased from 81 to 3% with a negative variance of -96 %, values decreased from 56.9 to 15 %, with a negative variance of -79 %, and patients with accepted items exhibited a negative variance of -95 %. The percentage of rejected claims was 60% and only 5% of justifications were accepted. Reimbursements and approvals for medications prevailed at 67.5 and 61 % respectively. 17 institutions and 399 patients were involved with an average of 2.2 claims/patient.

Conclusion:

Medical claims and approvals decreased, and medications as approved and reimbursed events prevailed. The high percentage of rejected claims and the low reimbursement rates of the medical claims make the billing process inefficient and ineffective. They also delay payments to health care facilities and increase the risk of health crisis with negative consequences for the health of population.

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