The judges prevent clinics from claiming compensation from the plans on behalf of patients

Health plans won in court the right to refuse payment for medical consultations, tests and other procedures performed by unaccredited clinics and labs that use a patient login and password to request payment from operators.

According to the court procedure, the institutions publish advertisements and entrust the patient with treatment at no cost in exchange for a credit allotment, that is, a contract is concluded in which the beneficiary transfers his rights to the clinic.

With fake payment receipts and possession of the user’s access data, they demand refunds in his name. When the amount falls into the beneficiary’s account, he issues bank slips or requests to transfer the amount through bank transfer.

When the operator refuses to pay, clinics also file complaints with the ANS (National Agency for Complementary Health) on behalf of beneficiaries, which can result in fines for the plans. Finally, if they can’t get compensation, they ask the patient to pay.

This practice, which is considered fraudulent, actually took place before the Covid pandemic, but it spread after the health crisis. In addition to lawsuits, there are ongoing police investigations and business mobilization to curb this, as many schemes are being introduced by companies.

Last month, CCR (Companhia de Concessões Rodoviárias) fired 100 employees after discovering, in an internal investigation, misuse of plan compensation. Also in April, Itau laid off 80 employees for the same reason.

says Cassio Alves, medical supervisor of Abramge (Associação Brasileira de Planos of health).

There is no volume survey involved in these fraudulent refunds. Many of the cases are still being investigated by the operators in the police and prosecution investigations.

According to data from Fenasaúde (the National Federation of Complementary Health), which represents large groups of health insurance companies, the total volume spent by operators from 2019 to 2022 jumped from R$6 billion to R$11.4 billion, an increase of 90%.

In the same period, the increase in aid expenditures with payments to doctors, clinics, laboratories, hospitals and suppliers of materials and medicines amounted to 20% (from R$171.8 billion to R$206.5 billion).

At Abramge, the total amount of reimbursements increased from R$6 billion in 2019 to R$10.9 billion in 2022. Just as an illustration, if these last year’s refunds were accompanied by the general variance in aid expenditures, the disbursement would have been R$7.2 billion. by entity. Alves estimates that “the fraud has been located in R$3.7 billion.”

In the decisions, the judges allowed operators to refuse reimbursements that come unaccompanied by proof of payment of expenses by the beneficiaries and decided that ANS suspends any penalties on the plans for this reason.

Assisted repayment is not provided for in the Plan Act and, therefore, the issue is not regulated by the ANS. However, the agency has been discussing with the complementary sector ways to prevent the legitimate consumer complaint against plan (NIP, Notification of Initial Mediation) mechanism from being used by fraudsters.

In the lawsuits, the accused laboratories and clinics argue, in their defense, that consumers transfer the right to credit in their favor and that this will be a service that adds value to the service, and brings convenience, by reducing bureaucracy in the operators’ reimbursement system. But the judges rejected these appeals.

Folha has managed to reach four decisions taken in São Paulo this year. In them, there is a resolution for clinics and laboratories to refrain from requesting a login and password from the beneficiary or requesting payment on their behalf, under penalty of a fine of up to R$50,000 for each act of non-compliance.

“[Os estabelecimentos] Created a real intention to circumvent the payment system and what is authorized to be redeemed in contracts, harming consumers and distorting freedom of choice and free competition,” says an extract from a May 8 decision by Judge Clarissa Rodríguez Alves, of the Fourth Civil Court of São Paulo.

In another decision, Judge Carlos Eduardo Borges Fantasini, of the 26th Civil Court of the Central Court of the Judicial District of the Capital, when granting an urgent exemption to an operator, considered the subsidized compensation to be an “obviously offensive and misleading advertisement”.

For him, this practice violates the Consumer Protection and Good Faith Act, “because in a reimbursement system, it is clear that the consumer makes the payment first, and then reimburses himself with the health insurance company.”

On March 21, Judge Andrea de Abreu, of the 10th Civil Court of the D.C. Central Court, justified the decision in favor of one of the operators, arguing that “asking for confidential patient data, such as login and password, puts consumers at a clear disadvantage, and they end up being weakened.” in the necessary confidentiality of their medical data.”

According to Vera Valente, Executive Director of Fenasaúde, in addition to participating in a scam and risking retribution, recipients who provide their login and password information to third parties put their personal information at risk. “It can be used, for example, to change the bank account linked to the payment or to request payment for actions not performed. It’s a blank check.”

It says there are several types of fraud, such as clinics and laboratories that even before a patient undergoes a medical consultation ask for a login and password and actually run a series of tests, many of them unnecessary and overpriced, followed by requests for reimbursement.

In the lawsuits, requests for PSA (prostate antigen) screening, used in prostate cancer screening, for women have been mentioned.

Another frequent situation, according to Valente, is when a user performs a procedure that isn’t covered by the plan (applying Botox or plastic surgery, for example), and, in agreement with clinics, requests payment with a receipt for another type of service that it’s covered. “There are many cases where people know they’re wrong. They’re going to have a tummy tuck, and the doctor says they have an inguinal hernia.”

For Cássio Alves, from Abramge, there are patients who clearly agree to fraud and benefit from it, but there are many more who are motivated by naivety or lack of knowledge.

In March, Fenasaúde launched a Health Without Scam campaign to educate beneficiaries about the harm caused by fraud (which ultimately makes monthly fees more expensive) and mobilize the sector in the fight against them. The campaign has now reached businesses.

“We will distribute materials targeting human resources on how to handle these benefits and explain to their employees,” says Vera Valente. (Vulbras / Claudia Colucci)

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