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12/5/2016
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Published: 12/02/2016
The National Supplementary Health Agency (ANS) ordered the suspension of the commercialization of 69 health plans from 11 operators based on complaints related to healthcare coverage, such as negative and delayed care, received in the third quarter of 2016. The measure is part of the Periodic monitoring carried out by the ANS by the Assistance Warranty Monitoring Program.
"When we prevent the entry of new consumers into plans that are not serving their customers satisfactorily, we act in a preventive manner and alert the operators to the urgency of adopting measures to improve the assistance provided. In this way, we preserve the consumer that is already in these plans, which tend to have the standardized service. With the reduction of complaints, the operators could have the sale released in the next cycle, in three months, "explains the Director of Standards and Product Qualification, Karla Santa Cruz Coelho.
Results of the 3rd quarter of 2016
In the period from 01/07 to 09/30/2016, the ANS received 16,043 complaints of an assistance nature in its service channels. Of this total, 13,956 complaints were considered for analysis by the Service Assurance Monitoring program. Excluded are complaints from operators that are in portability of deficiencies, out-of-court liquidation or in the process of portfolio disposition, whose plans could no longer be marketed because the companies are in the process of orderly exit from the market. In the evaluated universe, 90.4% of the complaints were solved by ANS mediation via Preliminary Intermediation Notification (NIP), which ensured the solution of the problem to these consumers with agility.
The suspended health plans together have about 692 thousand beneficiaries. These clients continue to have the regular assistance to which they are entitled, being protected by the measure, since the operators will have to solve the assistance problems so that they can receive new beneficiaries.
Of the 11 operators with plans suspended in this cycle, one had already suspended plans in the previous period, and 10 were not included in the last list of suspensions. At the same time, eight operators could re-market 22 products that were not sold. This happens when there is a proven improvement in the service to the beneficiaries. Of the eight operators, seven were released to re-market all products that were suspended, and one had partial reactivation.
The measure is preventive and lasts until the next cycle is announced. In addition to having the marketing suspended, operators who have denied undue coverage can receive a fine ranging from R $ 80 thousand to R $ 250 thousand.
Access here the list of plans with suspended marketing
Access here the list of operators with fully reactivated plans
Access here the list of operators with plans partially reactivated
See the ranking of all carriers
See the presentation of the results
Summary of Results of the Monitoring Program - 3rd tri / 2016
11 carriers with suspended plans
69 plans with suspended marketing
692 thousand protected consumers
22 reactivated plans
7 operators with total reactivation of plans (18 products)
1 operators with partial plan reactivation (4 products)
Profile of complaints in the analyzed period
Chart of care demands
Detailed information per carrier and by classification range
Since the first tri / 16 cycle has been released, beneficiaries can also consult information on the monitoring program by operator, checking the companies' history and checking, in each cycle, whether it has suspended or reactivated plans. The data are available since the fourth quarter of 2015, when the new methodology of the program, introduced by Normative Instruction No. 48/2015, began.
In order to provide greater transparency and allow consumers to compare, ANS also provides an overview of the situation of all operators, with the classification of companies in the four existing bands (ranging from 0 to 3).
Make the consultation by health plan operator
Questions answers
1. What is the purpose of the Assistance Guarantee Monitoring Program?
The Care Guarantee Monitoring Program has the objective of identifying, quarterly, the behavior of health plan operators in relation to the assistance provided to their beneficiaries. Based on complaints made to ANS service channels, it is possible to verify that the service is done properly and in a timely manner and to compare the operators according to the modality.
2. How is the methodology of the Assistance Warranty Monitoring program?
The methodology that has been applied since the third quarter of 2015 distributes the health plan operators in bands ranging from 0 to 3, with zero being the best result.
These bands represent the number of complaints considered to be pertinent regarding health care coverage (negative or delayed care, for example) in relation to the total beneficiaries of the operator. The comparison between the operators is according to the type of care: doctor-hospital or exclusively dental.
Interested parties can also consult the situation of all operators in the Service Assurance Monitoring program and analyze the companies that provide the best assistance and those that present the greatest risk in relation to the service they provide to their consumers. It is important to clarify that operators that are in the process of portfolio disposition and special / extraordinary portability of portfolios are excluded from this monitoring because they are obeying the rite of ordered exit from the supplementary health market.
3. How is the indicator calculated?
The calculation of the indicator that will place the operator in a certain range is done by dividing the number of complaints that indicate restriction of access to care coverage, processed in the NIP scope, by the average number of beneficiaries of the last three months informed by the operator. The operators that present the highest number of assistance claims, taking into account the number of beneficiaries and health care segmentation, will have a greater result in the indicator, being included in the upper bands of the monitoring.
4. What differentiates each of the 4 tracks?
Track 0 - operators without claims considered to be registered registered in ANS service channels.
Track 1 - operators that presented results below the median.
Range 2 - operators that had a result equal to or above the median and less than or equal to 50% above the median.
Range 3 - operators that presented results greater than 50% above the median. It also includes operators who fail to provide mandatory information to ANS.
5. What leads an operator to have the commercialization of plans suspended?
The identification of the risk presented by the operator and the recurrence in the most heavy band in two consecutive quarters are the factors that lead a company to have the commercialization of its plans suspended. Accordingly, if there has been no reduction of at least 10% in the Operator's Index (IO) from quarter to quarter or if its IO has been identified as discrepant, the commercialization will be suspended. It is important to emphasize that the operators that are in the most serious band can also undergo other administrative measures by ANS.
Source: Ans
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This article was translated by an automatic translation system, and was therefore not reviewed by people.