Health plans denounce network that embezzled BRL 40 million in fraudulent reimbursements

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Fenasaúde, a federation that represents 14 groups of health plans in the country, presented this Thursday (13) to the Public Ministry of São Paulo a crime report about a network of shell companies created with the aim of making fraudulent reimbursement requests on a large scale. scale against operators, with deviations totaling around R$ 40 million.

The report sent to the prosecutors of Gaeco (Special Action Group to Combat Organized Crime) gathers documents, invoices and information that endorse the complaint. 179 shell companies and 579 “orange” beneficiaries were identified.

In all, there were 34,973 fraudulent refund requests. Of this total, at least R$ 17.7 million were paid by four health operators. The remainder was denied upon proof of fraud.

There are several individual cases already being processed in court, but now, with the indications that there is a criminal organization articulating these frauds, the specialized group has been requested to act.

The investigation carried out by four operators associated with Fenasaúde (Amil, Bradesco Saúde, Porto Saúde and SulAmérica) had the help of artificial intelligence tools to cross-reference information and professionals who went into the field to investigate it over four months.

According to Vera Valente, executive director of Fenasaúde, the suspicion that there was a criminal group acting in the sector arose from an increase of up to 30% in requests for reimbursement of medical expenses verified by the plans in the post-Covid pandemic period.

“We mapped the cases and then we started to see coincidences of companies, beneficiaries, providers. By pulling this thread and crossing the data, we arrived at this scenario that involves expressive values ​​and that impact all beneficiaries”, she says.

In the scheme, criminals created legal shell companies, with “orange” partners, people who lend their documents to appear in the social contract, but who never used a health plan.
These companies do not physically exist, many have the same corporate name, with the same false address and the same economic activity. In some cases, even emails that are repeated.

Once created, insurance brokers (it is not yet known whether real or fake) acted as intermediaries with health operators. Fraudsters also opened consultation clinics and clinical and imaging analysis laboratories. All fake, but with real invoices.

“It has an existence on paper, before the Federal Revenue. But then you go to look for it, and the clinic doesn’t exist”, says criminal lawyer Rodrigo Fragoso, responsible for the case.

Receipts for health services that were never provided are stamped by doctors, but it is not yet known if they were actually involved or if the gang used this data without the professional knowing.

“It is a true criminal organization, with a business structure, division of tasks, paid people, with a fixed amount, very different from the pattern of occasional fraud that we are used to”, says Fragoso.

He says that it was possible to observe that in the organization there are people responsible for opening companies, others who play the role of insurance brokers and others who take care of opening fake bank accounts where fraudulent refunds are destined.

According to the lawyer, only an investigation by the Public Ministry, with police help, will be able to request a breach of bank secrecy and other measures to find out, for example, who is the final recipient of these funds from the refunds that ended up in fake accounts.

“Invoices are repeated. We saw, for example, a shell company with 20 employees who, on the same day, 15 of them were seen at the same clinic and requested a refund.”

In the document presented to the Prosecutor’s Office, Fenasaúde asks for the investigation of crimes of belonging to the criminal organization, misrepresentation and embezzlement.

other frauds

For Fragoso, the impacts of these frauds can be much greater than those raised in the preliminary investigation by Fenasaúde. “This scheme, specifically, is just the tip of a much larger iceberg.”

According to Vera Valente, the case serves as a warning to society. “The value of a fraud, of a service that didn’t happen, that is fake, comes to the care expense account. Everyone is paying. It impacts on the sustainability of the health system, on the predictability of expenses on the part of the plans.”

She claims that there are other fraudulent behaviors related to the reimbursement of medical expenses that are widely practiced, such as splitting receipts. For example: a medical consultation costs R$1,000, and the person is entitled to R$300 in reimbursement by the plan. She pays the R$1,000, and receives two or more receipts from the doctor, with different dates, to obtain a refund equal to or close to the amount paid.

According to Valente, there are also cases of receipts granted without any care provided and also the misuse of laboratory tests. “You go to a weight loss clinic, the doctor gives you a giant list of tests, often the collection is done at the clinic itself. Then they double the test order, and the plan pays for many things that were not done.”

There are cases in which health professionals propose to use the value of reimbursement for services not provided to pay for other procedures that are not on the ANS (National Supplementary Health Agency) list. “This is in an absurd dimension, with tentacles in every way. It ranges from the offender to the criminal. From the pickpocket to organized crime”, says Valente.

This month, Fenasaúde announced the creation of a management to prevent and combat fraud. According to data from a 2020 IES (Health Ethics Institute) study, 2.3% of everything invested in health is lost to fraud.

Considering that the budget allocated to the sector (public and private) in recent years corresponded, on average, to 9% of GDP, equivalent to R$ 630 billion, the country loses at least R$ 14.5 billion every year with fraud in the health. It is almost 10% of the budget for the health area in 2023 (R$ 146.4 billion).

With the frauds, operators lit the red alert and established stricter criteria for reimbursement of medical expenses. In channels like Reclame Aqui, the delay in granting reimbursement has been one of the main complaints of users against health plans.

“If you start to have a lot of wrong practice, the operator has to check much more carefully than what they are paying for. It becomes a snowball and ends up harming those who do it right, honestly.”

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