Assisted reimbursement – Fenasaúde warns of fraud risks

Assisted reimbursement – Fenasaúde warns of fraud risks

Assisted reimbursement deserves special attention from medical account managers and analysts at health plan operators. This is because Fenasaúde recently released a warning about sharing the health plan's login and password so that third parties can request reimbursement, obtaining a commercial advantage, which causes problems such as the lack of control over the procedures and exams requested.

The transfer of reimbursement rights by beneficiaries to third parties, a practice known as assisted reimbursement, is a source of concern among health plan companies. This conduct has been frequently adopted by clinics that offer this supposed benefit to clients in advertisements and campaigns on social networks. According to the National Federation of Supplementary Health (FenaSaúde), an entity that represents 13 large groups of health plans, there is no legal or contractual basis that can justify this transfer of the right to reimbursement to third parties.


How assisted repayment works

Assisted repayment or assisted repayment is a type of medical reimbursement where it is possible for the manager to help the patient with all bureaucratic and legal aspects for care in non-accredited networks. This way it is possible to avoid fears and cancellations of service in other networks.

The so-called “assisted reimbursement” is generally offered in exchange for the transfer of beneficiaries' personal data, such as login and password in the health plan operator's system. The beneficiary is promised the 'facilitation' of the reimbursement request process. However, explains FenaSaúde, with this data, providers can change the reimbursement request amounts according to each operator's contract, and even request reimbursement for exams and procedures not performed. Beneficiaries often make an agreement to transfer the amount received by the health plan to the clinic without any disbursement for the service.

“Assisted repayment is different from assistance provided by a family member, without the intention of making a profit. This type of practice brings great legal uncertainty to the provision of services, makes it difficult to predict the costs of health plans and puts at risk the defense of the interests of beneficiaries who collectively bear the costs of this type of action”, highlights Vera Valente, director- executive at FenaSaúde.


Fenasaúde warns of risks of assisted reimbursement

According to a publication on the Fenasaúde website, lawyers specializing in supplementary health agree. “Why are non-referenced doctors, clinics and laboratories interested in providing this assistance to patients, bearing the costs involved and the risks of default? Because the provider can increase the price a lot and can even divert the flow of patients from the referenced network”, explains Rodrigo Fragoso, a criminal lawyer who works to combat fraud against the healthcare system.

Lawyer Angelica Carlini, a specialist in consumer relations in the insurance market, also explained that by disclosing that it is possible to assist the consumer with the health operator, as long as they share their access data to request reimbursement in the operator's system or application, the service provider is committing a crime against consumer relations.

“By stating that the refund can be made as a financial transaction, that is, without due disbursement, the service provider is misleading the consumer, with false and misleading statements about the nature of the service”, he explains.


What the Superior Court of Justice (STJ) says

The understanding of the Superior Court of Justice (STJ) corroborates this understanding. In November, the Ministers ruled that: “there is no way to allow clinics and laboratories not accredited by the health plan operator to create a new form of reimbursement (“assisted or assisted reimbursement”), in complete distortion of the very logic of the system recommended in the Law no. 9,656/1998, even giving rise to situations of lack of control in verifying the adequacy and values of the consultations, procedures and exams requested, which could harm the entire insurance actuarial system and, ultimately, the insured themselves”, the document states.


Use technology to avoid fraud in your health insurance company

Nothing better than combining technology, well-structured processes and 100% transparency to drastically reduce or even eliminate any risk of fraud. Smartphones and the technology available today are not just for people to connect through social networks. They are useful for thousands of services, and one of them is medical bill audit.

The largest supplementary healthcare providers in Brazil use the SAUDI system to carry out the entire medical audit process. This is because SAUDI brings together all the benefits of technology to keep medical bill audit processes automated and in compliance with legal requirements, making it possible to record medication information, fees and procedures directly from the medical network.

Health service providers also have the facility to send all Authorization Forms directly through the system. And it is fully customizable. This means that, if your operator requires a specific routine that SAUDI does not yet provide, it can be developed and integrated with other modules to meet the needs of your operation, keeping the entire process running correctly and transparently for future consultations. and necessary audits.

Contact us and learn how SAUDI and its modules can help you position your healthcare provider to GROW in a healthy way, while you receive praise for your excellent results at the forefront of the healthcare processes. medical bill audit! ; )

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Main types of fraud in supplementary healthcare and how to protect your healthcare provider


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