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ADRES implementará auditoría inteligente de cuentas médicas: alianza estratégica con Microsoft, Amazon, Google y Oracle
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En un movimiento estratégico para modernizar la gestión financiera del sistema de salud colombiano, la Administradora de los Recursos del Sistema General de Seguridad Social en Salud (ADRES) anunció la firma de una alianza con cuatro de las empresas tecnológicas más influyentes del mundo. Este convenio tiene como principal objetivo desarrollar un sistema de auditoría inteligente para la revisión de cuentas médicas, basado en inteligencia artificial (IA).
Los aliados estratégicos incluyen a Microsoft (representado en América Latina por TI724), Amazon Web Services (a través de su aliado Blend360), Google Cloud (con el respaldo de Servinformación) y Oracle (junto a su socio Entelgy). Estas compañías competirán en el diseño de una Prueba de Concepto (PoC), que deberá estar finalizada en septiembre de 2025, y de la cual se seleccionará la solución más eficaz para ser adoptada por la entidad.
De “pagador ciego” a “pagador inteligente”: transformación institucional
El director de la ADRES, Félix León Martínez, destacó el alcance estratégico de esta transformación al declarar: “Damos un paso más en nuestro objetivo de dejar de ser un pagador ciego y convertirnos en el pagador inteligente del sistema de salud. De esta manera, se optimiza el uso los recursos destinados a la atención en salud que reciben millones de colombianos”.
Actualmente, la auditoría de las facturas médicas presentadas por las IPS se realiza de manera manual, lo que genera cuellos de botella, demoras en los pagos y riesgos de fraude. Con la implementación de este sistema basado en inteligencia artificial, la ADRES busca reducir significativamente los tiempos de respuesta, detectar anomalías de forma automatizada, y garantizar un manejo más transparente, eficiente y seguro de los recursos públicos destinados a salud.
Proyecto SIA: modernización del control fiscal en salud con auditoría inteligente
Esta iniciativa forma parte del Proyecto Sistema Inteligente de Auditoría (SIA), con el que la ADRES busca no solo transformar sus procesos internos, sino también avanzar hacia una infraestructura digital robusta que permita una trazabilidad completa del ciclo de la auditoría, desde la radicación de cuentas hasta el pago final a las IPS.
El enfoque del SIA contempla integrar tecnologías como:
- Algoritmos de aprendizaje automático (machine learning) para validar patrones inusuales o inconsistencias.
- Análisis semántico de textos médicos para auditar descripciones clínicas y diagnósticos.
- Módulos de verificación cruzada de tarifas, códigos CUPS y criterios de habilitación.
- Interoperabilidad con los sistemas de información hospitalaria y las plataformas RIPS.
Con esta evolución, se pretende fortalecer el pago por resultados, evitar facturación inflada o servicios no prestados y, en última instancia, mejorar el flujo financiero entre aseguradores, prestadores y el Estado.
Evaluación competitiva y elección del aliado tecnológico
La participación de empresas de clase mundial en este proceso posiciona a Colombia en la vanguardia de la digitalización del control fiscal en salud en América Latina. Según lo informado, la ADRES seleccionará finalmente una sola compañía, entre las cuatro que desarrollen la PoC, con base en la efectividad del prototipo, su capacidad de respuesta a las necesidades normativas nacionales, su integración con la arquitectura tecnológica de salud del país y la calidad de los algoritmos de IA aplicados.
La alianza no implica una contratación directa por parte del Estado en esta etapa, sino un proceso competitivo de innovación abierta que culminará con la elección del socio tecnológico que acompañará la implementación completa del Sistema Inteligente de Auditoría.
Transparencia y control: prioridades del sistema de salud
La auditoría de cuentas médicas representa uno de los eslabones más críticos y vulnerables en el sistema de salud colombiano. La gestión oportuna y transparente de estos recursos afecta directamente la viabilidad financiera de las IPS, la continuidad de los tratamientos médicos y la percepción de legitimidad del sistema por parte de los ciudadanos.
Con esta apuesta tecnológica, la ADRES responde a múltiples llamados de los actores del sector, incluyendo gremios, EPS, hospitales y entes de control, que han señalado la necesidad de modernizar los mecanismos de revisión, pago y supervisión.
Esta innovación también se alinea con los principios de eficiencia, trazabilidad y lucha contra la corrupción promovidos por organismos multilaterales, y podría convertirse en un referente regional en materia de auditoría digital para sistemas públicos de salud.
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