If you have health insurance, suffer an accident and are referred to an emergency room of the Unified Health System (SUS), the law requires that the bill for the service be sent to your operator. However, instead of complying with the law and paying the invoices, some companies prefer to question the amounts in court and accumulate debts with the Union –“locking” billions of reais, which could be invested in improvements in the public health service.
Because of this strategy, private plans owe about R$ 2.9 billion to SUS, according to the National Agency for Supplementary Health (ANS), responsible for overseeing the sector and collecting payment.
The biggest debtors are Hapvida and NotreDame Intermédica, which announced a merger in March this year and together owe at least R$ 648 million (22% of the total). They deny that judicialization and late payments are a business strategy and accuse ANS of carrying out improper collections. Among the services with the most outstanding claims are hemodialysis, kidney transplantation, radiotherapy and childbirth.
But while the debts drag on in court, the SUS ceases to receive resources provided for by law. With the BRL 2.9 billion of the total debt, equivalent to USD 588 million, it would be possible to buy at least 58 million doses of vaccines against Covid-19 (considering the value of 10 dollars per dose paid by the Ministry of Health in the vaccines), which would be enough to immunize 29 million people.
Hemodialysis, kidney transplantation and radiotherapy are among the procedures with the highest rate of ‘default’ to SUS by health plans Pillar Quarry/Senate Agency
“These values are missing. This is an injustice, favoring companies, which are always in the blue, while the SUS is underfunded”, says researcher José Antonio Sestelo, representative of Abrasco (Brazilian Association of Collective Health) in the Supplementary Health Commission of the CNS (National Health Council), an agency that monitors the actions of the Ministry of Health.
Why is the charge made?
Reimbursement to the SUS is contained in the Law 9656 of 1998, and was created as a way to balance the accounts of the public system and prevent operators from earning twice: with monthly fees paid, and without spending on customer service. The measure has no financial impact on the user, as the bill is sent to the health plan.
“Companies charge their customers and include the offer of certain services. If the patient used the public hospital, the operator is earning without working, without spending on staff and structure, so the SUS asks for reimbursement”, explains Sestelo.
Part of the health plan companies have billion-dollar debts with the Union, blocking investments in improvements in the SUS Reproduction/Reporter Brazil
The money raised goes to the National Health Fund (FNS), an account with funds destined to the federal, state and municipal governments for various purposes, such as the construction of health units, the purchase of equipment and the payment of professionals. From this fund comes part of the resources that finance the vaccination campaign against Covid-19.
Merger defaulters
The debtor ranking is led by Hapvida, which has a debt of R$382 million and has never paid a single cent. Next comes NotreDame Intermédica, with a debt of R$265 million, of which it paid off only R$9,306 (0.003% of the total), according to ANS.
The merger of the companies, which still depends on the approval of Cade (Administrative Council for Economic Defense), will create the country’s largest health plan operator, with 8.4 million customers and net income of R$ 18 billion.
Hapvida is the leader in the North and Northeast, and NotreDame, in the Southeast. Both are focused on customers with lower purchasing power (the average monthly fee is R$220) and have become known for investing in their own service network and using aggressive buying strategies from local competitors.
Listed by Forbes as one of the richest men in the world, oncologist Candido Pinheiro is the founder of Hapvida, which owes R$ 382 million to SUS Ceará Government/Disclosure
Behind Hapvida is one of the richest men in Brazil, 74-year-old oncologist Candido Pinheiro Koren de Lima, who is on Forbes’ ‘2021 World Billionaires’ list, with his fortune estimated at $4 billion. In 1979, he founded the Antônio Prudente Clinic in Fortaleza (CE), which in 1993 would become a health plan operator. In 2018, it announced IPO on the stock exchange.
NotreDame was created by physician Paulo Sérgio Barbanti in 1968, in São Paulo. Over time, the company made a series of mergers and, in 2014, it became managed by the American fund Bain Capital.
According to the Central Bank, both are registered in the Active Debt due to the non-compensation to SUS. According to the bank, Hapvida joined Cadin in 2013 (a sort of “Serasa” of companies and people who owe the federal government), and NotreDame has been on the list since 2016.
Despite the fact that this registration limits the obtaining of credits and tax incentives, both companies not only continued to grow and buy competitors in recent years, but also currently provide services to public agencies.
In May, the Hapvida signed a R$ 4.1 million contract with Sudam (Superintendence for the Development of the Amazon) to serve active and inactive employees and their dependents for a period of one year. NotreDame Intermédica, in turn, has contracts with the Armed Forces, as the one signed in February with the Navy Technological Center in São Paulo, in the amount of R$ 1 million.
How is the indemnity calculated
The operators’ debt is calculated by the ANS based on the crossing of information on services provided by the SUS and users of health plans. Technicians evaluate the data and correct any errors before sending the invoice to the private plans, which receive reports on the clients served by the SUS, such as name, date, place and procedure performed. After notification, operators can administratively appeal, questioning amounts or inconsistencies.
In the appeals phase, the most common arguments of the operators are that the patient was in a waiting period, that the service is not provided for in the contract or that it is in a co-payment format (when the beneficiary needs to pay part of the amount). If the argument is proven, ANS can cancel the charge or recalculate it. Otherwise, payment slip is issued and interest starts to be counted.
The fact that only complex outpatient care, such as chemotherapy, can be reimbursed also generates criticism from specialists, since consultations and other procedures of lesser value also generate expenses for the SUS Marco Santos/Ag. For
The ANS data show that the standard strategy of some companies is to appeal administratively and then push the debt to court. “Of course, companies don’t want to pay, so the operators will extend it until the time they want”, says Isabela Soares Santos, a researcher at Fiocruz’s National School of Public Health.
Process failures
The judicialization is based on three points, according to lawyer Luiz Felipe Conde, president of the Special Committee on Supplementary Health of the Federal Council of the OAB (Ordem dos Advogados do Brasil). Companies question the ANS calculation, as the agency uses the SUS service table as a basis and multiplies the value by 1.5; the moment when the interest starts to pay and the term in which the debts expire.
ANS states that it has invested in technology and personnel to streamline and improve processes, following a recommendation by TCU. “Since 2015, the effective payment rate has remained above 70%, reaching more than 80% in 2019”, claims. Despite this, due to the pandemic and the suspension of deadlines, the default increased and payments fell to 63.2% in 2020.
Despite the changes implemented by ANS, the data show that the system still has flaws. The first of these is the long term of one year until an operator is notified. To Repórter Brasil, technicians from the agency said that this period has already reached four years and that, to reduce it even further, it would be necessary to change the procedures in the SUS, which takes time to consolidate the data and make them “ready” for the ANS do the math.
Another problem is that only high complexity outpatient care (APAC), such as hemodialysis and chemotherapy, and hospital admission procedures (whose acronym is AIH) are charged, leaving out the consultations. “These technically lesser outpatient expenses generate expenses for the SUS and are not reimbursed.”, explains Sestelo.
Questioned by Repórter Brasil, the NotreDame Group did not recognize the debt of R$ 265 million with the SUS, despite the company being included in the “dirty list” of debtors of the Union.
The operator argues that, “when it understands that the charges are not relevant, having exhausted the means of administrative defenses and exercising its right to discuss in court, making 100% of the respective guarantee deposits”.
Hapvida already stated that it would manifest itself through Abramge (Brazilian Association of Health Plans). In a statement, the association criticized the delay of the ANS in notifying the operators, affirmed that the judicialization is a right and that is why it questions the charges, even after the Supreme Court decides that the compensation to SUS is constitutional. Read the placements in full.
These nearly R$ 3 billion of this default to SUS (debt until December, R$ 1 billion of which is in dispute), added to the growing profits of the operators and the merger of ranking leaders, are a portrait of private health in Brazil: “This market has become highly oligopolized and this increases the political influence of companies”, says Sestelo, from Abrasco.
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source https://pledgetimes.com/health-plans-owe-r2-9-billion-to-sus-value-would-buy-58-million-doses-of-vaccine/
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