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HomescienceChanges to the rules governing decertification of hospitals by health plans begin...

Changes to the rules governing decertification of hospitals by health plans begin in September

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In September, the decision enters into force and includes new rules Medical Insurance. Now, when operators Certification of any clinic, hospital or servicethe consumer can request Mobility To another plane Without the need for deficiency.

Leticia, 5 years old, was born with a rare genetic syndrome and needs constant treatment, with doctors from different specialties. The girl faces a battle between adults and health plans.

“She needed to have an urgent surgery, because the pressure in her eye was very high and the health insurance did not have coverage in this hospital, and she had to contact a lawyer to be able to perform this surgery in a timely manner so that she did not suffer additional damage to her eye,” Monique Fonseca, the child’s mother, said. “Her eyes.”

Retiree Regina Diniz will have to undergo surgery to remove a kidney tumor at another hospital because the health plan excluded the hospital where she was already being treated. “Now I will have to have a dangerous surgery for cancer in a hospital I don’t trust,” he says.

Regina and Monique, Leticia's mother, pay the same amount to the health plans, R$1,600 a month, and say they are not satisfied with the service. “My feeling is, 'I made one plan and they gave me another plan, right?'” Regina says.

According to a study conducted by the National Agency for Complementary Health (ANS), there were more than 2,500 complaints about the withdrawal of accreditation of hospitals and clinics in 2023. In the first five months of this year alone, there have already been 1,152 complaints.

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One of the main complaints concerns the deaccreditation of hospitals, medical clinics and laboratories. The number of cases related to health plans in the São Paulo Court of Justice has doubled in one year. Amid many complaints, the NSA created new rules that will take effect in September.

With the new decision, the user will be able to change health plans without any need, as explained by health lawyer Elton Fernandez.

“Even if a person has a pre-existing disease and is undergoing treatment, if they are removed from hospital, they will be able to go to a new provider without a waiting period and continue treatment where they left off,” he says. .

For lawyers, this change will provide more protection for consumers, who currently have only one way out: going to court. “It has become increasingly common for people to not only have a good doctor, but also have the assistance of a good lawyer to ensure the right provided by the answer and the legislation,” says Fernandez.

The association that represents health plans explains that decertification is mandated by law. “If we have networks that provide better efficiency, a higher quality service at a lower cost, then we need to move, we need to change that network, because we have to have that commitment to use it in the most efficient way possible, see ‘Financial resource that does not belong to the operator,’ Again, it belongs to the contracting party, the health plan, and we are here to manage it,” answers Marcus Novaes, CEO of the Health Plans Association.

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The big problem is that, very often, the user is not notified that the plan is no longer accepted in the health unit he used to go to.

“Our rule requires that there be communication. When it comes to the hospital, they have to contact us and file and inform them that they will make these changes within 60 days, and they also need to notify and inform all beneficiaries that these changes will happen,” says Paulo Roberto Rebelo Filho. ANS Director.

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