Revenge and a sense of impunity discourage doctors from reporting health plans to APS

Of about 100 complaints that health professionals filed with the National Agency for Complementary Health (ANS) in 2021, due to alleged contractual disputes with health insurance operators, only nine resulted in representation documents that could lead to some punishment for companies.

According to the ANS itself, almost all complaints from health providers accepting medical plans were made either because the health plan operator resolved the issue before preparing a notice of violation, or because the process did not progress due to a lack of information to support the claim.

I am not surprised by this result. Unfortunately, over time, the agency that was created to oversee the operation of the operators began to act on behalf of the operators,” criticized the Paulista Association of Medicine (APM) Professional Defense Director Maron David Corrie.

According to Corey, the number of complaints reaching the agency is much lower than the true dimension of disputes between workers and companies. For the ANS, the problem is the fear that the health professionals themselves will do some harm if they identify themselves.

“There are indeed cases where medical entities send complaints from professionals who fear retaliation if they are identified. They are well-documented and well-documented complaints, but nevertheless, the response takes time and, in most cases, there are no practical results. Hence the disappointment of the professionals and the lack of Number of complaints lodged,” added Corey, explaining that for practical reasons, in recent years, APM and other entities have sought directly to operators to try to resolve professionals’ complaints.

On the 31st, the APM and the Brazilian Medical Association (AMB) released the results of a survey conducted with 3,043 physicians from across the country serving health plan clients.

Eight out of ten respondents said: Already encountered restrictions from operators When describing the performance of laboratory or imaging tests to their patients. Just over half of respondents (51%) said they had already experienced difficulties when their clients were admitted to hospital, and 53% said they had already been pressured to anticipate medical discharge for patients in hospital.

Another frequent problem, according to professionals, is that health plan operators fail to pay for services already performed or medications and materials provided, the so-called flashing.

Best Behaviors and Practices

In a note sent to the report, the ANS ensures that it has always encouraged best behavior and practices for the sector. And remember that they have a specific reporting channel for receiving, from health professionals, complaints about problems with health insurance operators – but, legally, the professional needs to identify himself and collect a series of documents supporting his complaint, as well as to meet all scheduled appointments.

Regarding the results of the AMB and APM survey, the ANS commented that cases of refusal to carry out care and procedures refer to “beneficiary service [cliente] of health plans”, and it was not possible to determine whether there was interference with medical independence. Regarding the lists, the agency ensured that when it received a complaint, it notified the operator to present its defence, and analyze the situation within the legal time limit.

The ANS notifies the operator in search of a solution to the problem. A portion of the complaints end up being filed at this point with their resolution. The agency explained that those that are not resolved are sent to other sectors of the agency so that the assistance and economic and financial issues of operators that could stimulate such behavior are analyzed, because there is no specific breach in the code of conduct.”

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