When a beneficiary of a health plan is served by the Unified Health System (SUS), the insurer is obliged to reimburse the government for the treatment. These transfers are in the billions and are expected to increase due to the Covid-19 pandemic, a disease caused by the new coronavirus.
In practice, it is a return to society of the values borne by the public system, but which should have been the responsibility of private companies.
The National Agency for Supplementary Health (ANS) does not yet know how much will be passed on to the Ministry of Health, but says that the amount will be disclosed and charged in March 2021. From that date, companies will pay in 15 days.
In previous years, the treatment of pneumonia and influenza (flu) had an important participation in the set of hospitalizations in the SUS, which were reversed in compensation made by the ANS. With the pandemic, these cases increased in 2020.
Hospital assistance in case of hospitalization by Covid-19 is mandatory coverage by health plans since the beginning of the pandemic. Initially, the case records in the SUS were part of non-specific procedures.
The payment, according to ANS, occurs from the integration of management databases of the Ministry of Health and the agency itself. The process starts about 12 months after treatment. During that time, billing for care is performed by SUS, sent and processed in the ANS database, until notification of the occurrence with the operators, when the administrative procedure is opened.
“With this, considering the schedules and deadlines for the SUS Compensation, the events related to the pandemic that occurred from the first quarter of 2020 and eligible for this process will be known from the first quarter of 2021, being forwarded to the operators and publicly disclosed to from March 2021 ”, explains the ANS, in a note.
Throughout the pandemic, visits for respiratory syndromes and Covid-19 were highlighted. The agency says that it follows the assistance changes and the standards adopted in systems for recording the attendance made, so that they can be reversed in reimbursement.
ANS transferred R $ 491 million to SUS in the first half of this year. In 2019, the reimbursement totaled R $ 1.151 billion. Since the beginning of the reimbursement to SUS in 1998, ANS has charged health plan operators a total of R $ 6.32 billion, corresponding to more than four million services.
In 2015 and 2019, kidney transplants, bacterial disease treatments and multiple surgeries stand out among the services performed at the highest prices charged in the hospitalization group, while hemodialysis, radiotherapy, post-transplant patient follow-up and adenocarcinoma hormone therapy prostate cancer account for the highest values charged among medium and high complexity outpatient care.
Since 2000, the reimbursement to SUS has sent R $ 1.36 billion to enrollment in active debt, of which R $ 753.81 million occurred between 2016 and 2020. In the first half of this year, the amount forwarded reached R $ 277, 29 million.
The Brazilian Association of Health Plans (Abramge), an entity that represents insurance companies, stresses that the impacts of the pandemic are still unknown. “This year the health system has gone through an unprecedented period and only now is it starting to move towards normality”, he highlights, in a note.
The organization considers the current model to be “counterproductive” and claims that it harms both the administration of the service network and the assistance management.
“The health plan operator starts to contain information about the procedure performed in the public network long after the event, making it impossible to make adjustments to the network or, when the situation allows, to include the beneficiary in a more qualified care program”, he concludes. the text.