Interview: what is SUS reimbursement and how does it work

We spoke with Dr. Elio Tanaka, a doctor graduated from UFPR and a specialist in General and Pediatric Surgery at Hospital dos Servidores do Estado (RJ), and the subject was the reimbursement to SUS, the legal obligation of the operators of private health plans to reimburse the expenses of the public system when its beneficiaries are served by the Unified Health System.


CR – What is reimbursement to SUS?

Tanaka – It is the regulatory instrument of reimbursement, by the operators of private health care plans, of the expenses incurred in the care provided by SUS to its beneficiaries, provided that the services provided are covered by the health plan contract, as provided in article 32 of the Law No. 9,656 / 1998.

CR – Are all the services that the beneficiaries of health plans make through SUS eligible for reimbursement?

Tanaka – No. The reimbursement occurs whenever beneficiaries of health plans are served in the public network to perform procedures that are provided for in the contracts or in the list of procedures edited by the National Supplementary Health Agency (ANS) and under the terms of the contract, such as geographic coverage, grace period, etc. To this end, ANS identifies the patient served by the public system and crosses that patient’s information with the database of the regulatory agency, whose user registry is supplied by health plans.

Based on the identification of a user with a health plan that has been attended by SUS, and having verified in the databases that the service should have been guaranteed by the plan, ANS notifies the operator about the amounts that must be reimbursed. Thus, an administrative proceeding is initiated in which the operator may present a defense and contest the charge. Generally, 20% of the administrative resources made by the operators in relation to identified / notified services are granted, that is, of the total of notified procedures, only 80% are subject to collection.

CR – Are operators obliged to pay for calls that are made on the public network?

Tanaka – Yes, the payment is determined by law. If the operator does not voluntarily make the payment of the amounts calculated as reimbursement, after 75 days of notification, the records are forwarded to the debtor’s registration in the Informative Register of Unpaid Credits of the Federal Public Sector (CADIN) and in the Active Debt, as well as for the consequent judicial collection.

CR – What is done with the funds collected by ANS through reimbursement?

Tanaka – The amounts paid by the operator as a reimbursement to SUS are destined to the National Health Fund and are reapplied in priority programs of the Ministry of Health.

CR – Why do the resources obtained from the reimbursement not go back to the states and municipalities where SUS services were performed?

Tanaka – With the advent of the normative alteration promoted in article 32, § 1, of Law nº 9.656 / 1998, due to the edition of Law nº 12.469 / 2011, there was an important change in the destination of the transfer of the values ​​obtained through the reimbursement procedure SUS. The amount collected started to be fully transferred to the National Health Fund (FNS), and is no longer shared with other health providers.

This new operation provided greater security in sending the amount of reimbursement, given that the forwarding of the amounts was previously deposited in several bank accounts, which, in many opportunities, as they are out of date, ended up provoking the return of the credit to the agency. regulator. In addition, the concentration of funds in only one entity of the SUS allows an improvement in the spending of the resources sent.

CR – Is the purpose of the reimbursement to finance health?

Tanaka – No, reimbursement is a mechanism for regulating Supplementary Health. Through it, ANS can verify how the operators are performing in the fulfillment of contracts.

CR – Why is the amount that ANS charges operators not the same as the amount collected?

Tanaka – The current legislation guarantees operators the right to appeal the ANS notification, if the company considers that the reimbursement is undue. In this case, the company can file defenses – at first (objections) and at second instance (appeals). And, if the appeal is denied (rejected), the operator also has the possibility of paying in installments. Thus, generally the funds charged at a certain maturity end up having the payment postponed due to resources and the possibility of payment in installments that are guaranteed by law, which causes the difference between what is charged and what is actually collected in the period.

If you have any questions other than those explained above, write here in the comments!