Supplementary healthcare in Brazil is a dynamic and highly regulated sector, directly impacting the lives of millions of beneficiaries. The guidelines of the National Supplementary Health Agency (ANS) are constantly evolving to ensure greater transparency, financial balance and quality of care. In recent years, several regulatory updates have been implemented, requiring health insurance companies and medical bill auditors to adapt.
This article will cover the ANS's most recent regulatory changes, their operational impacts and the best practices for auditors and directors of operators to remain compliant and ensure the financial sustainability of their companies.
The Role of the ANS and the Context of Regulatory Change
The ANS is the regulatory agency responsible for regulating, supervising and guaranteeing the proper provision of supplementary health services in Brazil. Its normative updates seek to ensure that operators fulfill their obligations, promoting greater security for beneficiaries and sustainability for the sector.
In recent years, significant changes have been driven by factors such as:
- Growth in healthcare costs: increase in medical expenses and technological advances.
- Judicialization of health: greater number of lawsuits involving healthcare coverage.
- Need for transparency and oversight: demand for greater control over information and data.
Check out the ANS' Main Regulatory Updates
Below, we highlight some of the regulatory updates in recent years and their direct impact on the management of operators and the auditing of medical bills:
Normative Resolution No. 514/2022 - Transparency and Access to Information
One of the most important changes was Normative Resolution 514, which establishes stricter transparency criteria for the disclosure of information on coverage, adjustments and services. For operators, this means the need to improve internal communication processes with beneficiaries and partners.
Impacts on account analysis:
- Greater traceability of information sent to operators.
- Need for more detailed audits to avoid discrepancies between what was reported and what was actually carried out.
- Increased documentary requirements to prove the legality of charges.
Roll of Health Procedures and Events (Continuous Update)
The ANS has adopted the model of continuously updating the List of Procedures, allowing new treatments and technologies to be included more quickly. This has a direct impact on auditing, as there are constant changes to the mandatory coverage of plans.
Impacts on account analysis:
- The need for auditors to be constantly updated on new procedures and coverage criteria.
- Risk of disallowances due to ignorance of new additions or exclusions of procedures.
- Increased complexity in assessing the costs associated with new technologies.
Normative Resolution No. 555/2022 - Quality Factor for Service Providers
The introduction of the quality factor for provider remuneration establishes criteria based on performance indicators. Providers must consider these factors when auditing medical bills and negotiating contracts.
Impacts on account analysis:
- More careful auditing of the quality of the services provided.
- Evaluation of indicators such as average length of stay, readmission rate and adherence to clinical protocols.
- Adjustments to service contracts to bring them into line with the new criteria.
Normative Resolution No. 565/2023 - Rules for Coparticipation and Deductible
NR 565 brought changes to the rules on co-participation and deductibles, defining percentage limits and the need for greater transparency in charging beneficiaries.
Impacts on account analysis:
- Rigorous auditing to ensure that charges are within the established limits.
- Billing systems need to be improved to avoid inconsistencies.
- Greater demand for communication to beneficiaries about the amounts charged.
I apologize for being out of date with the previous article. There were, in fact, significant regulatory changes in supplementary health in 2024, implemented by the National Supplementary Health Agency (ANS). Below, I present an update on the main rules and their implications for directors of healthcare operators and auditors of medical accounts.
Normative Resolution No. 585/2023 - Changing the Hospital Network
In force since December 31, 2024, NR 585/2023 establishes new rules for the replacement or exclusion of hospitals from the accredited network. Operators are obliged to notify beneficiaries individually of changes to the hospital network at least 30 days in advance. In addition, the norm extends the portability rules, allowing beneficiaries who are dissatisfied with the exclusion of a hospital to migrate to another plan without meeting minimum periods of permanence or price range compatibility.
Impacts on account analysis:
- Contract monitoring: Auditors should check that provider replacements comply with the new regulations and that communications to beneficiaries have been carried out properly.
- Cost assessment: Changes in the hospital network can have an impact on operating costs, requiring a detailed analysis of new partnerships and their financial effects.
Normative Resolution No. 593/2023 - Default Notification
Published in 2023 and coming into force in 2024, NR 593/2023 defines that beneficiaries can only have their plan canceled for non-payment after failing to pay at least two monthly installments, consecutive or not. The rule also allows for new forms of communication about default, such as recorded telephone calls, emails and text messages, as long as the beneficiary confirms receipt.
Impacts on account analysis:
- Collection processes: Collection procedures need to be reviewed to ensure compliance with the new communication requirements and deadlines before cancellation due to default.
- Default management: Auditors should monitor the financial impact of changes in default rates and cancellation policies.
Proposed New Rules for Health Plan Adjustments
In 2024, the ANS proposed significant changes to the rules on health plan readjustments, especially for group plans. The proposals include the definition of clearer criteria for readjustments, limits on co-payments and new rules for terminating contracts. These changes aim to bring greater transparency and balance to relations between operators and beneficiaries.
Impacts on account analysis:
- Contract review: Operators must review existing contracts to bring them into line with the new adjustment and co-payment guidelines.
- Transparency in readjustments: It is essential to ensure that readjustment processes are transparent and comply with the new regulations in order to avoid penalties.
Normative Resolution No. 623/2024 - Meeting Requests for Procedures
Published in December 2024, NR 623/2024 establishes new service rules for requests for procedures or services covered by assistance submitted by beneficiaries. The rule aims to standardize and speed up service, ensuring greater efficiency and transparency in the process.
Impacts on account analysis:
- Processing requests: Auditors must ensure that operators are complying with the new deadlines and procedures established for handling beneficiary requests.
- Documentation and records: It is important to keep detailed records of all requests and responses for auditing and regulatory compliance purposes.
New Compliance and Corporate Governance Standards
The ANS has encouraged the adoption of good corporate governance practices, demanding greater control over fraud, waste and operational risk management.
Impacts on account analysis:
- Implementation of more robust internal audits to identify possible fraud.
- Adoption of technology tools to monitor atypical billing patterns.
- Reinforcement of team training to ensure compliance with the new standards.
Challenges and Opportunities for Medical Account Directors and Auditors
Faced with these regulatory changes, medical billers and medical bill auditors face significant challenges, but they also have opportunities to improve operational efficiency.
Main challenges
- Adapting internal processes: adapting workflows to meet the new ANS requirements.
- Continuous training: keeping teams up to date with constantly evolving regulatory changes.
- Managing cost increases: avoiding financial impacts resulting from disallowances and undue charges.
Opportunities for improvement
- Investment in technology: automated auditing tools can reduce errors and increase the accuracy of account analysis.
- Strategic partnerships: collaboration with service providers to ensure compliance and quality.
- Improved governance: implementation of stricter internal control and regulatory compliance processes.
Good Practices for Efficient Management in the Face of New Regulations
To ensure that operators are prepared for the changes, some good practices can be adopted:
1. continuous monitoring of standards: maintain a direct communication channel with the ANS and participate in training offered by the agency.
2. Automation of Audit Processes: use of artificial intelligence to detect inconsistencies in medical bills.
3. Team training: provide regular training to ensure up-to-date knowledge of the standards.
4. Proactive Disallowance Management: implementation of internal mechanisms to preventively review bills before they are sent for invoicing.
5. Transparency in communication: ensuring that beneficiaries are aware of the rules on co-payment, coverage and adjustments.
Current scenario
The regulatory changes promoted by the ANS require health operators and medical bill auditors to be attentive and prepared to ensure compliance, financial sustainability and quality in the services provided.
The regulatory updates implemented by the ANS in 2024 bring significant changes to the management of healthcare operators and the auditing of medical bills. It is crucial that directors and auditors are aware of these new rules, adjusting internal processes and ensuring compliance to ensure financial sustainability and the quality of services provided to beneficiaries.
Use the SAUDI system to keep your operator compliant with the ANS at all times
Adapting to the new standards should be seen not just as an obligation, but as an opportunity to optimize processes and improve management in the sector.
The implementation of good practices, continuous training and the use of technology are essential factors in meeting the challenges posed by the constantly evolving regulatory landscape.
As SAUDI in action your operator is always in compliance with the ANS, because we adjust our medical audit system whenever necessary to meet a new requirement.
Request one now free SAUDI demo and DISCOVER how to start working with MUCH more peace of mind and security! ; )
