Increasing complaints from health plan customers due to the exclusion of doctors, laboratories and hospitals in 2023

Complaints from health plan customers increase due to the exclusion of doctors, laboratories and hospitals in 2023

In 2023, complaints from health plan customers increased due to disqualification Doctors, laboratories and hospitals.

Housewife Lace Matos asks for divine help every time she calls the health plan. After paying tuition for 24 years, he tries to schedule cataract surgery. Only then did he find out that the clinic where he always attended his appointments had been turned away. The plan indicated that there was a hospital in another city.

“Unfortunately,” he says, “I don’t know that. They could be an excellent hospital; I don’t disparage them in any way. But these are places where we don’t have a history.”

Complaints, such as those from Lais in Brazil, have increased. information from National complementary health agencywhich supervises the plans, it was found that there were more than 12 thousand complaints in 2020, about 16 thousand in 2021, and more than 25 thousand in 2022. And in 2023 and until May, there were already more than 13 thousand.

In São Paulo, this year alone, he appeared Public Ministry Already opened seven procedures to determine cases of ineligibility. Right to health lawyer Renata Vilhena Silva says many operators do not maintain the quality of the plans they sell.

“Operators buy hospitals and try to restrict consumers to use their own network, to contain costs, and this significantly reduces the authorized network and customer rights,” he explains.

president wrappersWhich represents the main health plans in the country, says that the growth in complaints reflects the increase in the number of insured persons and the increase in measures that fell during the pandemic, and that replacements are made with equivalent services, as specified. according to law.

“Individual perception can change. But it’s not because hospital brand A or B is better or worse. What I have to evaluate is what are the quality indicators, what is the readmission rate, what is the clinical outcome of that hospital. Now, the most important And, as we always score, is that the coverage does not change “, defends Renato Casarotti.

By law, health plans can exclude labs and professionals, but they must be replaced with equivalent ones and clients must be notified 30 days in advance. They can also change hospitals in the affiliate network, replacing them with others that provide the same quality service. In this case, in addition to informing the beneficiaries, it is also necessary to notify the ANS. And if you want to reduce the contracted network, you need to seek permission from the regulatory agency.

According to the ANS, it is up to the operators to put all information on replacing non-hospital providers on the website. The same applies to the disqualification of the hospital network. Failure to do so will result in a warning and a R$25,000 fine. If the operator does not comply with the rules of equalization and does not report the replacement of the hospital entity, the fine is R$30,000.