Health plan: Companies dismiss employees for fraud – 06/03/2023 – Market

The growth of cases of fraud against health plans, especially through irregular reimbursement requests, has led large companies to open internal investigations to identify and dismiss employees who circumvent the benefit rules.

In recent months, the infrastructure company CCR dismissed more than 100 professionals after an investigation that pointed to an additional cost for the company of more than R$ 12 million over five years due to the misuse of the plan with practices such as dividing the reimbursement amount by procedures unrealized, overpriced or unnecessary with shell clinics.

A similar situation happened at Itaú, which fired 80 professionals after detecting misconduct by workers in reimbursement requests. The two cases had repercussions in the market, encouraging other employers to study dismissals as a way to combat fraud.

According to Raquel Reis, CEO of SulAmérica, the reaction of contracting companies happens at a time when the health plan market itself is investing in efforts to try to contain the advance of scams.

She claims, for example, that from July the company’s application will require facial biometrics from the user, in an attempt to prevent irregular use by third parties.

Last year, Abramge (Brazilian Association of Health Plans) launched a manual to combat fraud, and FenaSaúde (sector federation) filed a complaint with the Public Prosecutor’s Office of São Paulo about schemes involving R$ 40 million in fraudulent reimbursements.

“We are being very vocal on this issue. We had a large increase in the team. We hired people and law firms to carry out investigations and intensify the number of criminal complaints and lawsuits”, says Reis.

Cassio Ide Alves, medical superintendent at Abramge, says that the sector has been noticing an increase in fraud since the beginning of the pandemic, driven by gaps favored by digitization and advertisements of schemes on social networks.

According to Alves, the contracting company turns on the warning signal when it discovers an unusual increase in the cost predicted by the actuarial calculation. With this distorted growth in claims, the company may pay an extra amount, in addition to the increase in the readjustment when renewing the contract.

“The company has means of verifying the data. Fraud usually leaves traces. Sometimes, a refund request appears for a query that was registered on the day the employee was traveling for work”, says Alves.

Vera Valente, executive director of FenaSaúde, says that she has scheduled meetings with industry representatives and professionals responsible for human resources areas from different sectors to bring information on the subject.

“The cost of what is done irregularly by an employee burdens the company and can lead to consequences such as layoffs, which are now happening, but it can also lead the employer to review the benefit and reduce the category of the plan”, says Valente.

Lawyer Luís Mendes, a partner at Pinheiro Neto and a specialist in labor law, says that fraud committed by the professional in the plan causes a breach of trust, which is considered a serious misconduct.

“It will be up to the company to determine whether it will apply a small penalty, a warning, a suspension or a termination of the contract for just cause”, he says.

In addition to dismissal for just cause, the employee may have to respond criminally for the act and return the embezzled money, according to Domingos Fortunato, partner at Mattos Filho, also in the labor area.

He points out that dismissal for just cause requires care from the employer, with a structured investigation that confirms and supports the measure.