Complaints against withdrawal of services by health plans jump 170% in 3 years, says ANS

Complaints against withdrawal of services by health plans jump 170% in 3 years, says ANS
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User complaints against health plans continue to grow in Brazil. According to data from Procon-SP, during 2022, 9,537 complaints were registered with the agency. Last year this number jumped to 13,230, an increase of 38% in the period. In the first 2 months of this year alone, the agency has already recorded 2,416 complaints. There are many complaints, but one in particular has caught the attention of professionals working in this sector: network deaccreditation.

A survey by ANS (National Supplementary Health Agency) shows that the number of complaints against network disqualification jumped more than 170% between 2020 and 2023, going from 923 complaints to 2,505. This year, until April, 971 complaints had already been recorded, a higher amount than that recorded throughout 2020.

“We have seen an increase in complaints of deaccreditation. It is difficult to specify how this has happened, but there is a strong movement in the market towards the precariousness of services and operators’ links”, assesses Marina Magalhães, researcher at Idec’s health program. According to her, the ANS regulates all deaccreditations, both for individual and collective plans, but the criteria are stricter for the hospital network. In this case, the operator has, for example, to notify the agency, which has to authorize the deaccreditation. However, the same does not happen when it comes to clinics and laboratories, which have more flexible rules.

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The rules for network de-accreditation must follow 2 criteria:

  • 30 days prior notification to the user
  • replace with another equivalent – ​​same region, coverage area, quality

“The Health Plans Law defines that the operator is not obliged to maintain the accredited network forever, but it has to follow rules and just because it is not obliged does not mean it will change the profile of the services that the customer has contracted”, highlights Fábio Santos , partner at Vilhena Silva Advogados and specialist in health law.

Lawyer Desirreé Franco, from Goulart Penteado, comments that it is important, at the outset, to highlight that the act of de-accreditation carried out by operators does not imply any legal violation. “Health plans can deaccredit laboratories and hospitals when necessary, and must inform customers about the change 30 days in advance,” she says.

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Desirreé Franco remembers, however, that the change is conditioned on maintaining the level of service that the deaccredited laboratories and hospitals presented, that is, the new accredited ones must contain the same quality as those that were replaced. “Promoting the maintenance of the quality of the previously accredited network is a way of ensuring that no losses are borne by consumers”, he highlights. Furthermore, highlights the lawyer, it is necessary for the new network to be accredited in the same municipality as the previous one or, in case of unavailability in the region, the replacement must be located in a nearby municipality. “If the operator wants to reduce the accredited network, it will be necessary to send a request to the ANS, which must analyze the reasons given for granting authorization or not”, explains the lawyer.

In practice, however, this is not exactly what is happening. Experts consulted by InfoMoney report that health plan users have found it difficult to schedule exams outside the health plan’s own network. “This has been a strategy in the plans to save expenses and has been increasingly recurring”, comments lawyer Columbano Feijó, partner at Falcon, Gail, Feijó e Sluiuzas Advogados. Santos agrees that the own network is cheaper and that this has led many operators to remove laboratories that are not part of the own network from their list. “Take away those accredited and leave only your own network to serve without reducing the value. This is, to say the least, very unfair,” he points out.

What to do?

According to experts, solving this problem is not a simple task, but they give some steps for users who experience a similar situation to follow. Look:

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  • 1st – when you realize that there has been a de-accreditation, it is important to understand when the change occurred and why it happened, whether it was notified in advance and whether another equivalent establishment was placed in its place;
  • 2nd – if you realize that there has been an abusive de-accreditation, the next step is to open a ticket with the ANS and, at the same time, communicate it to the consumer protection bodies, which can also help in demanding explanations from the operator;
  • 3rd – if none of this works, the next step is to go to court. According to lawyers, the Judiciary has been very judicious in demanding that operators prove that they obeyed the rules. “Depending on the situation, it may even require re-accreditation”, says Santos.

Resident of Santos (SP), retired José Roberto da Costa Pinto, 71, found no alternative but to go to court after his plan disqualified the hospital where his wife is undergoing treatment for a rare cancer.

“Since 2019, my wife has been undergoing treatment at a reference hospital in São Paulo, which was accredited by the health plan. In January of this year, we received the information that we could no longer take her to undergo treatment there”, says Costa. “The closure of the health plan did not take into account the fact that my wife did not receive ‘medical discharge’ as stated by the doctor in his report and, in this case, the plan operator could never remove her from treatment”, emphasizes Costa.

In the action analyzed by the Court, the judge determined that the health plan will continue to pay for the patient’s treatment in the hospital where she was already being treated until 2026, when her medical discharge is scheduled.

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What the sector says?

When contacted, FenaSaúde (National Supplementary Health Federation) informed, through its press office, that the criteria for changing the network are set out in law 9656/98 and in ANS regulation. “The replacement of providers can occur as long as consumers are notified 30 days in advance. In the case of hospitals, it is also necessary to communicate to the ANS and approve it in the case of exclusion. To exclude non-hospital providers from the network, the conditions set out in regulation must be observed”, says the entity’s note, highlighting that negotiations between service providers and operators are carried out on an individual basis, with companies being responsible for organizing care networks that meet the needs of their beneficiaries and the maximum service deadlines, according to contracted products.

Abramge (Brazilian Association of Health Plans), in turn, reported that to guarantee the quality in the provision of health services and the sustainability of contracts, operators continually evaluate each of their products sold in accordance with ANS rules. . “This assessment may indicate the need to readapt the structure of products [planos de saúde] and discontinue others. It is worth noting, however, that the contract between legal entities may be terminated [a empresa contratante e a operadora] at the request of one or the other party, and must always be preceded by prior notification, observing the contractual provisions”, says the note.

Abramge highlights that, if the collective plan contract is terminated (for any reason) and there is a beneficiary or dependent in hospitalization, the originating operator must maintain all care until hospital discharge. Likewise, procedures authorized during the term of the contract are covered by the operator, as they were requested when the beneficiary’s relationship with the plan was still active. “It is essential to remember the right to portability, that is, the eligible beneficiary can change health plans without the need to comply with new waiting periods or temporary partial coverage.”

What the ANS says?

The ANS clarifies that Law 9656/1998 allows the de-accreditation of health service providers from the operator’s network, with different rules for hospital and non-hospital providers.

According to the agency, hospital providers can be replaced by another equivalent, upon prior communication to the consumer and ANS 30 days in advance. This communication does not need to be individualized (letter, email), but the operator must ensure that the beneficiary is aware of the information. The law also allows for the exclusion of hospital providers with network reductions. In this case, the services will be provided by providers who are already part of the network, however, the ANS must previously authorize this type of exclusion.
“It is worth highlighting, however, that, from September 1st, new rules for changing the hospital network will come into force, based on Normative Resolution 598/2024, which will be valid both for the removal of a hospital from an operator’s network , like exchanging one hospital for another.”
Non-hospital providers (offices, clinics, laboratories) can only be deaccredited if they are replaced by another equivalent. There is no need for authorization or communication to the ANS, but the operator must communicate to beneficiaries through its website and the Customer Service Center, 30 days in advance, and keep the information available for consultation, for 180 days.
“The operator who deregisters in violation of supplementary health legislation may be fined amounts starting at R$30,000 in the case of a non-hospital network, and starting at R$50,000 in the case of a non-hospital network. hospital.”
It is important to highlight that ANS acts to mediate conflicts between beneficiaries and operators, through the Preliminary Intermediation Notification (NIP), a tool created by ANS to speed up the resolution of problems reported by consumers. Under the NIP, the complaint registered in the Agency’s service channels is automatically sent to the responsible operator, who has up to five working days to resolve the beneficiary’s problem, in cases of assistance coverage, and up to 10 working days for non-assistance demands. “If the problem is not resolved by the NIP and if a violation of sector legislation is found, administrative sanctioning proceedings will be initiated, which may result in the imposition of sanctions on the operator, highlighting, among them, the imposition of a fine”, says the note .

The article is in Portuguese

Tags: Complaints withdrawal services health plans jump years ANS

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