Due to fraud in supplementary healthcare, this sector has been facing serious challenges in recent years. Many of them are linked to fraud in the system as a whole. Do you want to know what the main types of fraud are in supplementary healthcare? Follow this article written by SAUDI experts to help you protect and GROW your health plan operator, health service provider, such as hospitals, clinics and laboratories, benefit administrators, or your health plan contracting company for your employees, reducing risks and increasing results!

One of the main signs — or actually when people began to talk more openly about fraud in supplementary healthcare was in 2019, when Correio Braziliense published two reports detailing “Operation Esculápio” by the Civil Police and the Public Ministry of the Federal and Territorial District (MPDFT) ), which identified fraud in supplementary healthcare systems.

The issue is even more serious because, as pointed out in the study “Normative framework for preventing and combating fraud in supplementary healthcare in Brazil”, carried out by IESS and PwC Brasil, the absence of a regulatory act that provides for criminalization and appropriate sanctions culminates in a waste equivalent to 15% of supplementary health expenditure.

In 2018, according to the cost of assistance reported by the National Supplementary Health Agency (ANS), this amount was equivalent at the time to 24 billion reais.

For example, resources that could have been used to help beneficiaries and design important health promotion programs.

To help combat fraud, the study listed the most common practices in Brazil:

 

Fraud among service recipients, medical professionals and healthcare providers:

• Health Declaration: the beneficiary ignores the existence of pre-existing illnesses;

 

• Use of health plan: the non-insured person uses the beneficiary's identity to improperly enjoy a certain benefit;

 

• Refund request: excessively increase the service fee to excessively increase the reimbursement the health plan will receive;

 

• Kind of service: With the beneficiary's consent, the doctor will provide services other than those performed to obtain health plan coverage.

 

 

Fraud between care providers and suppliers of health:

• Determination of quantity or quality of materials: The hospital declares that it uses more hospital materials in the health plan, or makes an incorrect statement that the quality of the materials used is superior to the materials actually used in the procedure;

 

• Hospital stay: doctors unnecessarily extend a patient's hospital stay to increase the health plan's daily hospital stay.

 

Fraud among healthcare providers

• Services provision: The supplier or its distributor grants a certain percentage of commissions to professionals for instructions or use of their medicines/equipment;

 

• Judicialization: Doctors determine treatments or medications not covered by health plans for patients. The lawyer colluded with the doctor and asked the health plan to pay for the treatment/medication. Doctors and lawyers may receive commissions from suppliers and distributors.

 

Carrier fraud against other agents:

• When there is bargaining power between the operator and the hospital: the health plan provider is unreasonable or refuses to pay at will. This type of situation can be considered harmful to the relationship between agents, as it is simply about reducing costs to maintain working capital or reducing the amount paid to the hospital;

 

• Deliberately delaying bill payments in order to indirectly reduce delays and delay financial default;

 

• The common shareholders of the health plan have conflicts of interest with the hospital operator, and the hospital operator uses its position to benefit the operator's operation.

 

After all, why does this happen?

According to the study, one of the reasons is the lack of transparency mechanisms in Brazil.

A good example is the interaction between healthcare operators and service providers, their commercial relationship needs to be transparent.

For example, if benefits and commissions are paid, neither the patient nor society is aware and cannot be harmed by this.

According to the research, this type of relationship can explain some of the fraud problems identified and which can be controlled.

For example, in the European Union and the United States, transparency in this relationship is mandatory and public, and there are severe penalties for corruption.

Another factor highlighted by the research is the lack of transparency in the pricing system for health inputs and services and in the payment model for services provided.

In addition to opening space for inappropriate practices, they also make it impossible to compare and control costs in the different stages involved in patient care.

The study pointed out that this occurred mainly due to the most used payment method for medical services, that is, open accounts (service fees).

Using this model, the service account covers all costs, inputs, procedures and use of equipment, even in cases of failure, waste and corruption.

 

Solutions to protect your healthcare provider

Anti-corruption practices in healthcare are divided into different actions for each player in the sector, according to international studies in the area released by IESS.

Strategies need to aim at creating anti-corruption laws, transparency of information and implementation of new prospective payment models.

In all segments, the use of technology to computerize and unify systems is essential to generate financial data, quality indicators and sector efficiency, for example.

Technology helps health sector administrations also be able to analyze possible fraud in depth and combat wasteful spending.

The implementation of electronic medical records, for example, centralizes patient information and can be applied to operators in order to store financial transactions – so that these can be audited by third parties when necessary – taking into account the new parameters of General Data Protection Law, no. 13,709/2018.

In relation to health professionals, managers can apply training in codes of conduct and ethics and increase monitoring the use of material.

Already the patients must be informed on good practices in the use of health services as well as the consequences of bad practices.

Finally, combating illicit practices does not only depend on investment in cutting-edge infrastructure, but also on the constant improvement of human capital, which requires a change in mental model.

Now that you know the main types of fraud in supplementary health and what can be done to solve this problem, how about contacting the SAUDI and know all the resources that our system offers to protect your health plan operator from these and other possible types of fraud?

Speak to one of our experts and discover all the solutions present in the most complete and award-winning software on the market!

 

 

SOURCES:

http://portal.mec.gov.br/component/tags/tag/operacao-esculapio

https://www.pwc.com.br/pt/estudos/setores-atividade/saude/2019/arcabouco-normativo-para-prevencao-e-combate-a-fraude-na-saude-suplementar-no-brasil.html

https://www.pwc.com.br/