Refusal to authorize exams occurs when the doctor asks the patient for a procedure that the health plan considers inappropriate. The practice, criticized by several institutions that work in favor of consumer rights, is harmful to the health plan operator and also to the patient.

In this article, we will explain the main legal issues involved in authorizing procedures and exams, list the risks for the patient and talk about how health plan operators can act to overcome this problem. Check out!

What does the ANS determine?

Linked to the Ministry of Health, the National Supplementary Health Agency (ANS) is an institution that regulates practices in the health plan sector. Therefore, it is up to it to draw up a list of procedures that operators are obliged to comply with.

Among these procedures, they are not included in the role, for example:

• treatments for aesthetic purposes;
• artificial insemination;
• experimental or illicit treatments;

On the other hand, for contracts signed after January 2, 1999, within the limits of the agreement, when requested by the doctor, the services included by the health plan operator must cover:

• doctor's appointments;
• consultations with specialists from different areas, such as nutritionists, psychologists and speech therapists, during the hospitalization period;
• diagnostic and follow-up exams for infectious diseases;
• physiotherapy;
• chemotherapy, transfusion, radiotherapy, hemodialysis;
• preventive procedures.

When the health plan provider refuses to cover the exam or procedure requested by the doctor, the patient can contact the ANS or go to court. Having the contract and proof of payment of monthly fees in hand, it is easy to prove that the operator is denying authorization for a service agreed between the parties.

Therefore, the refusal to authorize exams and procedures is also harmful to the operator, causing it to lose credibility among customers and also lose money in lawsuits and lawsuits.

What risks can a refusal to authorize exams bring to the patient?

For the patient, the risk of not taking the exam requested by the doctor can be fatal. A diagnostic imaging exam, for example, shows the structure and functioning of internal systems. Clinical analysis tests can detect the presence of bacteria in the body.

Therefore, carrying out the tests correctly is decisive for, for example, determining whether the patient has cancer or tuberculosis and initiating appropriate treatment. Therefore, the risks of refusing to authorize tests range from worsening of the patient's clinical condition to death.

How can health plan providers overcome this problem?

Analyzing the contract and paying attention to regulatory standards is essential to act efficiently when verifying the requested exams. A Good Health Practices Certification, created by ANS, aims to contribute to the development of operators and has, among other practices, a program that encourages improvements in the quality of healthcare. Investing in smart technology like SAUDI It can also be a good option to help analyze requests.

We understand how the authorization of exams by the health plan operator works, and that failure to authorize it can have very serious consequences, and could even lead to the patient's death. We also saw that, to overcome the problem, operators must be very aware of the rules and the contract.

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