Campaign to reduce fraud against health plans – 03/15/2023 – Health
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Fenasaúde (National Federation of Supplementary Health) launches this Wednesday (15), Consumer Day, the Health Without Fraud campaign. The objective of the entity, which represents health plan operators in the country, is to warn about the growth of scams during the pandemic and the damage caused by bad practices.
According to Vera Valente, executive director of the federation, the annual impact of fraud and waste reached BRL 28 billion in 2017 and the health crisis worsened the situation. “The process of sending documents for reimbursement of exams and consultations was digitized and this facilitated fraud”, she says.
At the end of last year, the Sheet showed that deviations with reimbursements moved R$ 40 million. The case is still under investigation by Gaeco (Special Action Group to Combat Organized Crime) and two other crime reports have been registered since then, with the opening of nine police investigations.
With the investigations in progress, Fenasaúde is now launching an educational campaign with booklets, videos, interviews and posts to alert users and companies of the most common practices.
Among the recurring frauds are the falsification of identification documents and proof of address, irregular family or employment relationship and false proof of the previous plan to reduce shortages.
Other problems are requests for reimbursement of consultations and exams that have not been carried out or false clinical status. In this case, care not covered by the health plan is registered as necessary interventions or performed with the user’s “balance”.
“We got to the point where aesthetic clinics post on social networks that they work with health plan reimbursement mechanisms. The plans do not pay for any type of aesthetic procedure”, warns Valente.
The user arrives at one of these clinics, undergoes an examination for R$ 100 for R$ 1,000 and with the remaining amount has a massage, botox. This is fraud and the person must refuse to participate.
Still on the part of the user, other recurrent scams are the supply of login and password and the lending of the card to third parties, omission of pre-existing diseases, fractionation and falsification of receipts.
“The contract stipulates a refund of BRL 200. The user goes through a consultation for BRL 400 and is asked if he would like two receipts, so he can ask for the refund twice. hence the need to bring greater awareness”, says the executive director.
For her, consumers need to understand that the costs of undue reimbursements or procedures that should not be done will weigh on all users of the plan, since ultimately operators can increase monthly fees to cover the expenses.
“It damages health as a whole because those who cannot pay will leave the private system and impact the SUS (Unified Health System), it is a domino effect”, he assesses.
In terms of brokers, FenaSaúde lists the opening of shell companies, the sale of false health plans and the appropriation of values from customers and, on the part of providers, there are problems related to orthoses, prostheses and special materials, such as overbilling and unnecessary surgeries , in addition to charging for procedures not performed and tampering with exams.
In this sense, the entity advises users to give preference to trusted providers or those who are part of the accredited network of the health plan; make the refund request directly to the operator and never share the login and password of the plan application. In case of suspicion, it is possible to file a complaint with the operator or on the Fenasaúde website.
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