Health plan fraud: Idec sees disrespect towards consumers – 01/07/2024 – Market

Idec (Brazilian Institute for Consumer Protection), which has been following the public debate about fraud committed against health plans in Brazil, says that the issue has been treated by the sector with disrespect for customers.

The issue of fraud began to gain notoriety just over a year ago, when entities representing the sector began a movement to investigate the growth in cases and report the situation.

Among the efforts adopted to combat the problem, FenaSaúde (a federation that represents companies) set up management to increase oversight of the most common mistakes in the use of plans and presented criminal news to the São Paulo Public Ministry about shell companies created to request million-dollar amounts in fraudulent refunds.

Operators also initiated internal investigations, and large companies from different sectors carried out mass layoffs of employees accused of scamming corporate plans offered as benefits.

Among the examples of scams revealed, health plans list receipt splitting (when a doctor issues two or more receipts, to extract money via reimbursement, even though he provided a single service) and the falsification of the patient’s clinical status on the receipt issued. by doctors with the aim of forcing reimbursement for non-covered services (a practice that often involves cosmetic procedure clinics).

The provision of application passwords by customers to medical clinics is also a concern because it facilitates third-party access to patient data, which can be used to commit scams.

According to a report released in November by IESS (Institute for Supplementary Health Studies), fraud and waste caused losses of up to 12.7% of health plan revenues in 2022, with losses estimated between R$30 billion and R$ $34 billion.

Ana Carolina Navarrete, coordinator of the Idec health program, criticizes the way in which the matter has been handled by operators. She states that companies must have the responsibility to monitor their accredited and referenced network.

“The debate involving health insurance fraud is being disrespectful to those who support this market, which is the consumer. There are companies that, in bad faith, practice fraud and that can deceive and involve the consumer in this process, but the consumer is never guilty or should be held responsible”, he says.

For Navarrete, the debate about fraud is being used against the consumer, especially in the refund policy.

“Idec advises consumers to take some precautions, such as not sharing login and password, and to be suspicious of any procedure that is not standard with the operator, reporting it to the ANS [Agência Nacional de Saúde Suplementar] or at Procon. Now, the consumer cannot be penalized for company practices, such as, for example, those in which the operator requires the consumer to pay for the procedure out of pocket in order to be reimbursed. In practice, it is difficult for the consumer to be able to pay in full for a procedure costing R$10,000 or R$15,000. This is precisely why he hires a plan, to protect himself from this type of risk. By demanding payment, the operator undermines the very reason for the person to have a plan”, he says.

The alert on the topic of fraud came in the context of the crisis faced by health plans amid the consequences of the pandemic, when the sector plunged into an operational loss of R$11.5 billion in 2022, the worst result in two decades.

After the most acute phase, the current scenario points to a decline in accident rates, although still at a level above the pre-pandemic period.

According to the most recent data from ANS, the sector recorded a net profit of R$3.1 billion in the first three quarters of 2023.

In medical-hospital operators, the main segment of the sector, the operating loss still stood at R$6.3 billion in the year to date until the third quarter, offset by the record financial result of R$8.37 billion from investment remuneration.

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MAIN TYPES OF FRAUD IN SUPPLEMENTAL HEALTH CARE

Receipt splitting

It occurs when the doctor makes just one consultation, but offers several false receipts to the patient, simulating care to extract more money from the health plan through reimbursement. Generally, the pretext for starting fraud is charging a consultation price above the reimbursement limit

Health plan login and password request

It happens when the beneficiary reveals the login and password for their health plan application to clinics or doctors’ offices. Once accessed by third parties, the data, which should be confidential, can be used to change the bank account linked to the refund and receive compensation for false procedures.

Card loan

It is the fraud in which the user of a health plan gives up their card so that another patient, not a beneficiary, has access to a consultation or procedure pretending to be someone else.

False clinical status

There are many cases of this type of fraud in aesthetic treatments, which are not covered by health insurance. The professional performs a Botox or hair implant application, for example, but falsifies the patient’s clinical status on the receipt to force the plan to reimburse the patient for his service.

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POSSIBLE CONSEQUENCES FOR THE BENEFICIARY

• Termination of the health plan contract
• Loss of employment in cases where the plan is provided by the company
• Compensation actions
• Establishment of investigations

Sources: Abramge (Brazilian association of health plans) and FenaSaúde (national supplementary health federation)