Health plan: ANS receives 900 complaints per day – 09/09/2023 – Health

Anna Beatriz Maria Colli wrote a long statement on Instagram from the healthcare provider who cares for her six-year-old son. Her objective was to request the replacement of the gastrostomy tube and tracheostomy.

Richard has cerebral palsy and late last year he choked on a piece of bread during a seizure. He suffered a cardiac arrest that compromised oxygenation in the brain and depends on equipment to breathe and feed. “It’s already suffering everything we’re going through, and they still don’t make it easier”, says Colli’s post. “We need to appeal through complaints.”

Like Richard’s family, many have used filing complaints – on social media, at the ANS (National Supplementary Health Agency) or in the Judiciary – to try to resolve problems with health plans. At the agency alone, complaints rose from 67,690 between January and July 2019, before the Covid-19 pandemic, to 185,426 in the same period this year. There are almost 900 complaints a day.

Only registrations for maximum service time – when operators exceed the deadlines set out in the agency’s table for consultations and treatments – jumped from 4,666 to 29,035, an increase of 522%.

When questioned, the entities representing the operators state that the companies are working to improve the service infrastructure and systems, highlighting that the plans have their own channels for complaints and that the resolution rate in the sector exceeds 90%.

Main complaints

Richard’s father, Wagner Santos says that there were several appeals on social networks and three complaint records on ANS channels since October. First, to transfer the boy from the public hospital in Jabaquara, in the south of São Paulo, to a partner in Diadema, in Greater São Paulo. Then, to ask for home care (“home care”) and, now, to change equipment.

“We’re looking for a lawyer because there’s a lot missing. The plan doesn’t provide diapers, medications for convulsions and gastric protection, nutrition equipment. What we don’t find in the SUS, we’re buying with crowdfunding,” says Santos, who signed the plan in 2017 for the three children.

According to ANS, difficulties with reimbursement and partner networks were also frequently recorded on its channels, something that for lawyer Juliana Hasse, president of the Medical and Health Law Commission of the OAB-SP (São Paulo Section of the Brazilian Bar Association), Brazil), may be related to the lack of clear information about the contract signed with the healthcare provider.

“A large portion of the plans are acquired through corporate agreements and the user does not have a precise understanding of what was contracted, what is or is not included”, he explains. Individual and family health plans cover around 8 million beneficiaries, or 16% of the 50.6 million health care plan consumers in Brazil. The others are in corporate plans or by membership (hired through unions and associations).

Another difference between the modalities, points out Hasse, is the adjustment percentage. For individual and family plans, there is an increase ceiling established by the ANS, while the percentage of revision for collective plans is determined based on negotiations by the operators themselves, which also generates criticism. In the first seven months of this year, there were 8,413 complaints to the agency regarding monthly fees and adjustments.

Problems with the list of procedures and coverage also grew: there were 12,091 complaints to the ANS in the first seven months of 2019, compared to 16,634 this year.

“Many plans deny treatments that were determined by doctors and try to carry out simpler and cheaper procedures”, says lawyer Fabrício Posocco.

He mentions, for example, operators’ refusal to offer “home care”, as happened with Richard’s family. “These are situations that make relationships between patients and plans complicated and cause an increase in complaints.” According to the CNJ (National Council of Justice), at the end of 2022, there were 520,000 processes related to health in progress.

On the other hand, Hasse points out that this category also includes users who wish, for example, to perform cosmetic surgeries and try to deceive operators by presenting the procedures as repairs — which are covered. “Each case is different, it is difficult to standardize health actions”, says the lawyer.

As shown by Sheet, health care providers have obtained favorable court decisions against fraud schemes that involve irregular requests for reimbursement for consultations and exams. According to data from FenaSaúde (National Supplementary Health Federation), which represents large groups in the sector, from 2019 to 2022 the total volume spent by companies on reimbursements jumped from R$6 billion to R$11.4 billion, an increase of 90%.

The crisis in the sector has reached hospitals, which report payment delays totaling at least RS 2.3 billion.

For lawyer Hasse, the path to reducing complaints involves changes in plan management, including encouraging preventive medicine, reevaluating the service network and changing the doctors’ remuneration system, from the model based on the number of cases treated to another focused on the success of the conduct.

What do operators say?

In a note, Abramge (Brazilian Association of Health Plans) reinforces the importance of health plans in the country and the efforts of operators to meet the needs of beneficiaries in the face of operational losses.

“The sector has also faced significant impacts resulting from various frauds, including loans and counterfeiting of cards, misuse for aesthetic procedures, duplicate and fraudulent reimbursements for consultations, in addition to overpriced materials”, he says.

According to the association, operators are working to expand the service infrastructure, improve systems and organize networks and, thus, “bring Brazilian supplementary health to a sustainable path that promotes access to the private health system”.

FenaSaúde highlights that users can try to reach a direct resolution with the operator before registering a complaint with the ANS, and that the resolution rate in the sector is high.

“All associates offer customer service and ombudsman channels for clarifications, doubts and various issues. The demands received are used to improve processes and the vast majority of cases are resolved without the need to call external bodies.”

How does a complaint to ANS work?

ANS is the main channel for receiving demands from health plan users in the country and acts to mediate conflicts between beneficiaries and operators through the NIP (Preliminary Intermediation Notification). The tool was created to speed up the solution of problems reported by consumers, with a resolution rate of over 90%.

Under the NIP, the complaint registered in the agency’s service channels is automatically sent to the responsible operator, who has up to five working days to resolve the problem, in cases of assistance coverage, and up to ten working days for non-assistance demands.

If the problem is not resolved by the NIP and a violation of the sector’s legislation is found, an administrative process is initiated that may result in sanctions, including the imposition of a fine.