The entity says health plans create hurdles to releasing billions of dollars in payments to hospitals

“An unprecedented situation.” This is how Antonio Brito, CEO of the National Association of Private Hospitals (Anahp), explains the results of the survey conducted by the authority last week. According to information collected from 48 hospitals, these institutions are: R$2.3 billion was retained In payments for services already rendered to Health operators.

This amount refers to all types of procedures performed by people with medical insurance: from emergency care and examinations to requests for hospitalization. “All services provided in the hospital are invoiced to the operator,” Brito summarizes.

However, with the difficulties faced by operators, Anahab realizes that they are starting to create obstacles along the path leading to payment.

According to the Brazilian Association of Health Plans (Abramge), operators recorded an operating loss of R$ 10.7 billion in 2022. This is the worst result since the beginning of the historical series, in 2001. From January to June 2023, the account has already become negative by R$ 4.3 billion. By the end of this year, the value is expected to reach 10 Brazilian reals. Billion again.

According to Anahb, operators have set a single day for hospitals to issue an invoice for an entire month, which complicates the payment process. Another strategy in this regard was to set a monthly payment limit. “It doesn’t matter how many people are served, they only issue accounts up to a certain amount,” Brito says. Even if they give prior authorization for a particular action, questions later arise about what was done.

According to him, planners have the right to resort to what is called rejection, which is an analysis of the calculation with which they do not agree. It turned out that this indicator almost tripled. Before that it was 3.5%. In other words, if plans received a bill for R$100, they would subtract R$3.50. Now the rate has jumped to 9%. “The spirit of the explanation is to allow discussion of what is debatable. It is not a tool to save operators money at the expense of hospitals.”

The deadline for hospitals to receive payment for all the care they provide has nearly doubled. He adds: “No hospital has enough money to approve this amount after only 50 or 70 days.” “This has created a great deal of difficulty.”

Although we recently heard from 48 institutions, the entity represents 120 institutions in total. But Brazil has more than 3,500 private hospitals. “And every hospital that provides services to health plans is in the same situation,” Brito says.

He also points out that it’s not just hospitals that provide care to health plan users: there are laboratories, clinics and dialysis services, for example. “There are thousands of health providers,” says Anahp’s CEO.

According to Marcos Novaes, Executive Supervisor of Agramma, all services that have been performed but not paid for are provided, that is, the amount related to the procedures is separate and will be included in the hospitals’ accounts. “This did not happen for some reason, which delayed the process, such as analyzing some expenses,” he comments.

The executive confirms that the sector is experiencing an unprecedented financial crisis, and this is one of the reasons that prompted operators to increase refineries in light of the fees they receive. “The discussion started taking longer,” he says. “When you are in the middle of a crisis, and you are living at a loss, the standards really change, because every penny counts. The scenario is ultimately one of lack of resources. What we charge monthly does not mean paying medical expenses. So, we need to evaluate whether the medical expenses Actually consistent.

But he stresses that although it took longer to calculate the accounts, the money needed to pay for hospitals was preserved. “Of the disallowed amounts, some are due and will be paid. Others are not,” he says. “In the end, the operator will take the loss.” Novais highlights that the plans have suffered three consecutive years of losses. “It’s a complicated time.”

Among the reasons given for the loss of accounts, operators usually cite fraud, the arrival of treatments costing millions, the increase in the number of elderly people in the customer base, and the rule that allows an unlimited number of treatments and eliminations.

Brito is keen to stress that Anaha understands the crisis facing healthcare workers. He added: “But the problem must be solved through dialogue.” “This is a problem that will not be solved in isolation, that is, by operators transferring the problem to hospitals,” he says. “We need to find a way out for the sector as a whole,” he adds. “Old and experienced people in the area say they have never seen anything close to these values.”

Novis states that this communication already exists, and that it has never been as mature as it is now. “Today, when workers and hospitals sit at the table to talk, there is sensitivity. The cogs are starting to go wrong in this great system, but we know that all parties are trying to get along to make it work.