O deaccreditation of doctors, laboratories and hospitals has been a reason for increasing complaints from health plan customers in 2023.

Complaints from customers who do not find a certain specialty in the plan have been growing in Brazil. Data from National Supplementary Health Agency, which oversees the plans, show that there were more than 12 thousand complaints in 2020, almost 16 thousand in 2021, and more than 25 thousand in 2022. In 2023, until May, there were already more than 13 thousand.

In São Paulo, just this year, the public ministry has already opened seven procedures to investigate the disqualifications. In a recent interview with Jornal Nacional, lawyer specializing in health law Renata Vilhena Silva said that many operators do not maintain the quality of the plans they sell.

“Operators are buying hospitals and trying to restrict consumers from using their own network, to contain costs, and this is greatly reducing the accredited network and the rights of customers”, he highlights.

The president of Covers, which represents the country's main health plans, says that the growth in complaints reflects the increase in the number of insured people and the number of procedures, which had fallen during the pandemic, and that replacements are made with equivalent services, as determined by law .

“Individual perception can change. But it is not eventually because of the brand of a hospital A or B that it is better or worse. What I have to evaluate is what the quality indicators are, what the readmission rate is, what the clinical outcome of that hospital is. Now, what is most important, and we always record it, is that the coverage does not change”, argues Renato Casarotti.

What does the law say

By law, health plans can decertify laboratories and professionals, but they must replace them with other equivalents and must notify customers 30 days in advance.

They can also change hospitals in the partner network, replacing them with others that provide the same quality of service. In this case, in addition to notifying the beneficiaries, it is also necessary to notify the ANS. And, if you are going to reduce the agreed network, you need to request authorization from the regulatory agency.

Be careful with the ANS Fine

According to ANS, it is up to operators to place all information on the replacement of non-hospital service providers on the website. The same goes for the deaccreditation of the hospital network. Anyone who fails to do this will face a warning and a fine of R$ 25 thousand. If the operator does not comply with the equivalence rules and does not inform the hospital entity of the replacement, the fine is R$ 30 thousand.

Actions to avoid disqualification from your healthcare provider

Health operators play a fundamental role in organizing and providing health services to beneficiaries. To guarantee the quality of care and avoid the disqualification of service providers, such as doctors, clinics and hospitals, operators can adopt some important measures. In this article, we will discuss six actions that can be implemented to avoid being disqualified from your health plan provider. Continue reading until the end! ; )

Establish transparency and effective communication:

Transparency and communication are key elements for a healthy relationship between healthcare operators and service providers. It is essential that operators establish clear and transparent communication with providers, keeping them informed about the established guidelines, policies and criteria. This includes disseminating information about the accreditation, re-accreditation, and de-accreditation processes, as well as providing constructive feedback to providers. see how SAUDI can help!

Define well-established criteria:

To ensure the accreditation of quality providers, healthcare providers must establish clear and objective criteria. These criteria must be based on quality standards, technical capacity, experience, physical structure, human resources, compliance with regulatory standards, among other relevant aspects. By clearly defining these criteria, providers will know exactly what the requirements are to be accredited and maintain their status.

Carry out careful analysis:

Health care providers must carry out a careful analysis of service providers applying for accreditation. This involves evaluating your service capacity, quality of services provided, compliance with regulatory standards, among other established requirements. It is important that this analysis is carried out in a consistent and impartial manner, ensuring that only qualified providers are accredited.

Perform continuous monitoring:

Continuous monitoring of service providers is essential to guarantee the quality of care for beneficiaries. Health operators must establish monitoring mechanisms, such as technical visits, audits and collection of performance indicators. These mechanisms make it possible to verify whether providers are complying with agreed requirements and maintaining the quality of care over time. see how SAUDI can help!

Promote dialogue and negotiation:

The relationship between healthcare operators and service providers must be based on dialogue and negotiation. It is important to listen to the demands of providers, discuss possible improvements and seek joint solutions to identified problems. Furthermore, operators must ensure that negotiations are fair and transparent, respecting the interests of both parties.

Provide complaint channels:

Health operators must provide complaint and ombudsman channels for both service providers and beneficiaries. These channels must be efficient and transparent, allowing problems and disagreements to be resolved appropriately. By offering these communication channels, operators demonstrate their commitment to listening and resolving the concerns of providers and beneficiaries. By implementing these measures, healthcare providers can significantly reduce the risk of service provider deaccreditation. These actions strengthen the relationship of trust between the parties involved and guarantee the quality of service to beneficiaries.

Get to know SAUDI

O SAUDI is a system designed to maintain the “financial health” of Supplementary Health Plan Operators.

Our software automates the process of audit of accounts of medical service providers, enabling a clear vision for both sides (operators X service providers) and a significant reduction of unnecessary costs in the first 3 months of use.

Contact with our experts and learn about our personalized solutions for your healthcare provider to GROW in a very well-structured way!

And for more detailed information about the accreditation and re-accreditation processes, it is important for service providers to consult the specific guidelines established by the healthcare providers with which they wish to partner.