In civil law, fraud is associated with a deceptive act that aims to harm someone for their own benefit. Within supplementary health, there are some types, which can occur in different sectors and in different ways. Among them, one of the most common is fraud between the service recipient, the medical professional and the health operator. Within this relationship, some common forms of health fraud are the omission of a pre-existing illness by the beneficiary, the use of the user's identity by an uninsured person, and undue reimbursement requests.
Regarding refunds, it should be noted that, according to Abramge, they reached a record number in 2022. The companies transferred R$ 10.9 billion, which represents an increase of 21.1% compared to R$ 9 billion in 2021, whose value was already higher than the year 2020 (R$ 6.6 billion). Part of this exponential growth is attributed to the problem of fraud.
Other forms of fraud may occur, for example, in the relationship between operators and other agents, an example being the intentional delay in paying bills. There is also the practice of overpricing the amount of a consultation, or the transformation of it into two or more receipts, leading to an illegal profit with reimbursement for the clinic and/or the patient. In addition to the issue of waste and loss, some of these forms of fraud can also cause risks to the patient's health, through the omission of an illness, for example.
In addition to the cases of fraud that had repercussions recently, in 2022 the FenaHealth (National Supplementary Health Federation) had already identified shell companies that used “orange beneficiaries” and false service providers to request an undue reimbursement from the health plan. This led to a loss of around R$ 40 million, setting off yet another warning about this context.
Economic impact of fraud on health
In the economic sphere, these frauds promote harm that cannot be ignored. According to a reportage from the Institute for Supplementary Health Studies (IESS), R$ 28 billion was spent in 2017 to cover the costs of unnecessary medical procedures and fraud in hospital bills, which represented 19.1% of total care expenses.
From a more specific perspective, the IESS indicated that between 12% and 18% of hospital bills contain undue items and that between 25% and 40% of the tests performed are unnecessary. This results in around R$ 15 billion in fraud in hospital accounts and R$ 12 billion in requests for unnecessary exams. In 2022, according to CNSeg (National Confederation of General Insurance, Private Pension and Life, Supplementary Health, and Capitalization Insurance Companies), the frauds helped promote a loss of more than R$ 10 billion.
Regulatory fragility favors fraud
The report attributes as the main reason for this scenario the absence of effective control and transparency mechanisms to prevent or combat these frauds. The Brazilian regulatory and legal framework is still very fragile when it comes to health fraud, something that needs to be improved.
In addition, some behaviors, such as the sharing of a health plan portfolio or the act of requesting more than one reimbursement for the same medical procedure, are seen as socially accepted, which also does not contribute to awareness and change about this scenario.
A point adopted in the United States, for example, concerns considering the complainant as a partner of the state. He is encouraged to file this complaint and, eventually, is even remunerated. A CNSeg indicated that this fraud reporting mechanism led to the recovery of an amount of around US$ 2.4 billion.
Consequences of this conjuncture
This context of health fraud contributes to a Loss scenario which reverberates in the costs of all aspects of the supplementary health system, from operators to beneficiaries. Because of this, insurance companies and health operators have acted strongly to expose the impact of fraud and seek solutions to combat this.
One of the results of this scenario, specifically regarding fraudulent reimbursement requests, was that health plans gained the right to require proof of payment before reimbursing the beneficiary. Previously, the plans requested only the invoices for the services, but the operators began to observe cases of requests for reimbursement for procedures that had not been carried out or paid for.
In addition, there is investment in technologies that can guarantee the beneficiary's adequate access to the contracted service, such as voice or face recognition tools. Artificial intelligence also enters this scenario to suppress fraudulent use, acting by crossing data. In this sense, healthtechs have emerged focused on these solutions, identifying possible fraud in the use of health plans, working together with HR thinking about corporate plans, among other examples.
