LAUSR

Lombardy health system (SSL) separates the function of purchasing health benefits from the provision of services. Hospitals may be public or private and must be accredited and contracted with SSL to be refunded. The Health Protection Agency of the Metropolitan City of Milan covers about 3,500,000 inhabitants and 54 hospitals. The SSL has funded 548,250 episodes of ordinary hospitalization and Day Hospital. Total reimbursement of these admissions was 2,175,426,335 € with an average reimbursement of 3,697€ per average hospitalization of 7 days. The main diagnoses were cardiovascular (16.1%) and muscular-skeletal diseases (13.2%); the main reasons for hospitalization are birth and delivery (5.3 and 4.2% of admissions); hip and knee replacements absorbed 5.9% of total reimbursements and 2.7% of hospitalizations. The Operational Control Unit (NOC) evaluate settings and duration of hospital stays, diagnosis and procedures encoding on hospital discharge forms (SDO) and compilation of clinical documentation quality assurance. NOC make yearly inspections on a specific percentage of hospitalizations decided by the Lombardy Region by a targeted sampling mode or by a validation of hospitals' self-evaluations. In 2019 NOC evaluated 40,040 hospitalizations with targeted sampling mode that meant a total refund of 156,374,990 € and economic cuts in 19.2% of cases, that is 9,236,586 € (5.9% of the original reimbursement). In 2,428 cases NOC made changes in diagnosis or procedures of SDOs, in 916 cases reduced days of hospitalization, in 1,408 cases turned admissions into outpatient services and in 982 cases they applied a refund reduction due to quality failures in clinical documentation. Concerning self-evaluations, all admissions related to 2019, NOC analyzed 35,424 hospitalizations for a total refund of 130,781,615 € and modified 4,168 of them, the 11.8% of the total sample, returning an economic cut of about 5,259,532 €. NOC in 2019 evaluated 75,464 hospitalizations in 54 hospitals amending 11,838 admissions, the 15.7% of the total, returning an economic cut of 14,496,118 €, about the 5% of the total amount. NOC activities can have a remarkable impact on correct reimbursement of hospitalizations.