2023-08-11 15:52:47 - 24

Inclusion of US for Endometriosis Research in the ANS List

The Dynamics of the Health Market in the Negotiation of Readjustments and Accreditation of New Exams with Health Operators

Credit: CBR

For decades we have watched health insurance companies complain about high claims ratios, but they always reset the values of their beneficiaries' plans above the period's inflation. Nobody addresses the fact that Radiology Clinics and Diagnostic Imaging service providers, which are on average 15% of the cost of health insurance companies, have not responded to inflation in any year in the last 20 years.

For providers that manage to readjust, the average inflation replacement is extremely below inflation. In addition, they even have negative readjustments. A fact that should not occur, because the RN 503 of the ANS (National Supplementary Health Agency) regulates that “It is forbidden to impose forms of readjustment on the provider that are conditional on the loss ratio of the operator and establish forms of readjustment that maintain or reduce the nominal value of the contracted service ”.  

Accreditation market dynamics are largely to blame for follow-up. The Law of Supply and Demand is a concept that seeks to explain the formation and variation in the prices of products and services in a given market. If we have good doctors and good clinics accepting lower and lower prices, the tendency will be to get worse. We should all know the costs of our exams to help the market recover. Thus, prices below cost would not be practiced and buyers would have to bear the new values.

We always hear the fear of verticalization, but we need to remember that even for health operators, doing verticalized exams below cost is unfeasible! See how many health operators went bankrupt by verticalizing hospital services and Radiology and Diagnostic Imaging services.

Let's take a simple example! The Brazilian College of Radiology and Image Diagnosis has just managed to finalize the process of creating the exam Ultrasound for endometriosis research in the CBHPM (Hierarchical Brazilian Classification of Medical Procedures) of the AMB (Brazilian Medical Association), inclusion of the TUSS (Unified Terminology of Supplementary Health) of the TISS standard (Exchange of Supplementary Health Information) of the ANS (National Supplementary Health Agency) and inclusion on the list of mandatory coverage procedures of the ANS!

The values in reais of the procedure in the CBHPM 2021 version are R$ 2,239.02, but we all know that few health operators work with the latest versions of the CBHPM and much less with the values of UCO, Size and Film of its latest versions. So let's consider the worst case scenario and work with the table values in 2004, CBHPM 3rd Edition. The values would be R$ 407.26!

Credit: CBR

From this moment on, those who will determine the prices will be the service providers at the time of the negotiation for accreditation with the health operators. If everyone starts to accept accrediting the exam for very low values, this will be the new reference and once again we will be poorly remunerated.  

Remember that the health operator from this moment on is obliged to offer this exam to the beneficiaries! Remember that doctors often performed this complex exam and received it as a Transvaginal US! Don't let the cycle of bad pay perpetuate! Negotiate adequate values with your health insurance companies, while you are not accredited you can charge the amount you want as a private person. The clinics in your city should not be competitors in this endeavor, but partners to preserve our market with affordable prices for everyone!

Carlos Moura
Economic Advice
Brazilian College of Radiology and Imaging Diagnosis