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Operators must reimburse the Union when one of its beneficiaries uses the SUS for a service covered by the plan
Physician: Since 2013, doctors work in the field of medicine since many years. (Megaflopp / Thinkstock)
SUS has nearly R $ 2 billion to receive health plan operators
Nearly 2 billion reais because of the unified health system ( SUS ) were not transmitted by plan operators
Collection is scheduled by Law 9,656 of 1998, which defines that the operators must be in charge of the payment of the medical expenses. reimburse the Union whenever one of its beneficiaries uses the SUS for a service provided in the health plan contract .
Of this amount, R $ 346.27 million is suspended due to a court order. Other R $ 1.28 billion were simply not paid by additional health care providers and were enrolled in the active debt of the union, but about R $ 300 million did not have been paid but have not yet been registered for active debt. The data comes from the National Health Supplementary Agency (ANS), which regulates health plans and is responsible for calculating and collecting these reimbursements.
According to Fernanda Freire de Araújo, head of resuscitation at ANS SUS, many companies are betting on the judiciarization of the process to avoid payment, since the Federal Supreme Court (STF) has not yet decided whether repayment was constitutional or not. It was not until February of this year that the STF decided that the collection was legal and could be done by the ANS.
"Until the decision of the STF, we still had an uncertainty, constitutional or not, whether it was [as operadoras]"
According to the manager, the money deposited in court will not be refunded immediately to the SUS, because the shares are distributed in courts all over the country and this charge can take up to two years. In addition, all the money deposited in court does not refer to the question of the constitutionality of compensation. Some processes call into question, for example, the amount charged by the ANS for a certain medical procedure provided by the SUS
The decision of the STF will also help, according to Fernanda, in the collection of the amount recorded in the debt active. According to her, the reimbursement is not only a way to recover the money spent by the state under the medical procedure, but also to protect the beneficiary of health insurance. "The refund is a protection for the operator to continually form network and not expel everyone for the SUS.This is to ensure that the recipient has his contract covered "
However, all charges are no longer paid or are being challenged in court, and since 2013 health plans have already paid SUS $ 2.06 billion.
response, the National Federation of Additional Health (Fenasaúde), which represents the main operators of public health insurance plans, is responsible for providing funds to the National Health Fund to distribute them between states and municipalities. country's health authorities, indicated that companies resort to the courts when they consider that collection is undue (for example, in the case of procedures excluded by law, outside the geographical scope of the plan or during a delay of g thanks) and when ANS does not agree
According to Fenasaúde, it is necessary to strengthen the integration and flexibility of information between the public and private systems. "When a beneficiary of a health plan is served by the public network – as in road accidents – the operator must be informed as quickly as possible in order to promote the transfer to the public. private network, provided that injury to the recipient Operators or beneficiaries have no interest in using the public health network.Operators provide the supply and guarantee of services contracted with their beneficiaries ", indicates the note of Fenasaúde
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