Health plans are investing in anti-fraud research and tightening rules for claiming compensation

Health workers decided Tightening the rules for compensation for consultingAs this is one of the main tools used in fraudulent schemes. With this in mind, many plans have begun to require beneficiaries for proof of payment for the consultation or procedure. But new ways of circumventing the rule have already emerged: Clinics have been linked to informal digital banks, without approval from the Central Bank (BC). Hence, the operators Step up the fight against fraud.

The system generally works like this: Clinics or labs ask patients for their personal data and access to the health plan app. Once they have the data, they open an account in a digital bank set up by the company or its partner. Thus, the health service provider issues the documents as if the appointment had already taken place and the money is sent from the bank account (which was set up in the patient’s name in the irregular bank) to the clinic account, which results in the issuance of a payment receipt. Payment is then requested at the maximum rate in the contractual schedule for each beneficiary. Only after the payment is approved and paid does the clinic actually perform the consultation or tests.

Bianca Andreassa, an attorney specializing in medical and hospital law and a partner at Villemor Amaral Advogados, believes that the creation of fake banks by clinics or associations with these financial agents is happening to “Give a more legal face” to fraud, without the need for money to leave a bank account directly linked to the medical facility or its partners, in addition to facilitating tracking of refunds by clinics. In some cases, patients didn’t even know there were accounts in their names at the financial institutions used.

It is as if the patient took a loan from the bank to perform medical procedures, which would not be illegal. The problem is that the same people describe you [o exame ou tratamento] It is they who will “lend you” the money, he explains. “The illegality lies in the fact that the service provider is involved, even if not officially, in this process, which, together with the practice of subsidized repayment, gives that provider a blank check.”

The lawyer also explains that the scam traffic ramps up and becomes more granular as the scammer tries to get rid of the obstacles set by the operators.

Some of these associations of medical clinics and laboratories with irregular financial institutions were discovered by operators due to repeated requests for payment, always in high amounts and through the same financial institutions. When going over the information, it was noted that some of the data from the service providers—such as the registration address, phone number, or name of the partners—were the same as those from the banks used to request payment.

In a lawsuit filed by SulAmérica against a healthcare group (consisting of a medical clinic and a laboratory) and an alleged bank, the operator said it identified Unusually large number of refund requests relating to consulting and laboratory testing with purported proof of payment for the transactions mediated from the same bank.

“After conducting investigations, it was found that the first defendants (clinic and laboratory) have the same partners and maintain the identity of special interests with the third defendant (the alleged bank). In addition, although the headquarters are announced at different addresses, they are installed in the same location, to facilitate the practice of wrongdoing, and the phone number indicated on the CNPJ card is the same,” SulAmérica claims in the document, noting that although it calls itself a bank, the institution is registered as an information technology company, and operates secretly, without a license from BC .

In this case, SulAmérica sued the Federal Public Prosecution Service, as it involved a possible crime against the national financial system.

The health worker also argues that applications have been submitted to “unnecessary” exams by doctors associated with the scheme, many of whom had been requested even before medical advice.

“Even if they are not part of the approved network, prompt payment for services rendered is no longer required, distorting the regular meaning and exact meaning of the word payment, beneficiaries are led to believe that they will not be charged with the ‘facility’ provided and that the modus operandi is legal,” the company continues.

The document also contains reports Payees who say they do not know the financial institution to which payment was requested They claim that they were not aware of the wrongdoings of the service providers. They claim to have been duped and deceived into the crime, and some are seeking compensation for their wrongdoing She lost her job due to fraud being discovered By the contracting company of the health plan.

According to SulAmérica, the revenues of the economic group formed by the clinic and the laboratory with payments made to the operator amounted to R$ 17.4 million between 2019 and May 2023.

In addition to this case involving SulAmérica, there are several others with other health operators. In a case where Amil accused the same clinic that SulAmérica sued of fraud, the decision of the Court of Justice of the State of São Paulo (TJ-SP) is that there is no legal support to prevent the clinic from serving the beneficiaries of the operator, but that it must refrain from committing an illegal act. “This is still allowed [à clínica] Represent [os beneficiários nos pedidos de reembolso]provided that he obtained a power of attorney for this purpose and with prior payment by the beneficiary himself,” the ruling stated.

Thus the biggest offenses will be the payment without advance payments and the lack of knowledge on the part of the beneficiaries of the process about the services that will be sent for compensation.

In a third case, SulAmérica accuses 15 medical institutions, including clinics and laboratories, of fraud over requests for reimbursement based on ideologically false medical reports and invoices, which simulate a clinic’s justification for testing as well as simulate disbursement of payments, as well as ordering unnecessary pre-consultation examinations. In this case, TJ-SP’s decision deemed the practice arbitrary and upheld the procedure for the clinics to refrain from asking for login and password from beneficiaries, and from requesting payment and performing tests without prior consultation.

practice [de solicitar login e senha]though not prohibited by law, clearly indicates misuse of purpose, since in the defendants [clínicas e laboratórios] It is left up only to the provision of medical services, and puts consumers at a clear disadvantage, and they end up deficient in the necessary confidentiality of their medical data,” the judge writes in the ruling. “Similarly, there is no way to accept that a defendant performs clinical examinations without prior consultation with the patient and a case-by-case analysis.”

The practice of passing beneficiary data to a healthcare provider—which these companies sell as “assistant compensation,” where the patient doesn’t have to pay for a consultation or examination—is illegal (contrary to the legal system), Andressa says. However, clinics provide the service and sign contracts with patients that enable the company to seek reimbursement on their behalf.

The lawyer claims that The fraud scenario generates more bureaucracy for the beneficiaries – Even those acting under the law – get refunds, given the growing requirements to prove a claim is due.

It also comments that one of the last requirements some operators have made is to provide a patient’s medical history, which is prohibited by a CFM rule.

“It is possible to note cases where operators are even required to send copies of medical documents and medical records, which is contrary to the CFM rules, which only allow consultation in the environment, but do not allow the issuance of copies.” For her, “it is natural that in the face of new fraud, operators want to surround themselves with more security,” but they warn, on the other hand, about the impossibility of certain requirements, such as the medical record, which contains confidential information about the patient.

When asked about cases of fraud by medical and laboratory clinics, the Federal Council of Medicine has taken the position that it understands that all complaints of wrongdoing must be investigated by the relevant authorities, as a criterion for businesses and professionals to obey applicable legislation, while punishing those responsible for acts that constitute crimes.