Fraud in health plans made easier with telemedicine

Posted on 11/22/2022 7:36 PM / Updated on 11/22/2022 9:32 PM

Sao Paulo – Responsible for the loss of more than R$ 27 billion, fraud applied against health plans advances as health professionals adapt to the new ways of working provided by telemedicine. According to Bruno Gangoni, prosecutor of the Rio de Janeiro Public Ministry (MPRJ) and coordinator of the Special Action Group to Combat Organized Crime (Gaeco), there is already a criminal organization adapted to the new reality after the pandemic.

Among the main problems are the accelerated adaptation of criminals to ways of circumventing norms, even more so when it comes to the telemedicine environment, in which doctors rely more on medical examinations for a diagnosis than on anamnesis — the interview conducted by the doctor in service in order to identify the patient’s symptoms.

“You really have the structure of a criminal organization at will. All this misappropriation of money, not just anyone does”, explained the prosecutor during the meeting of representatives of the sector organized by the National Federation of Supplementary Health (FenaSaúde), this Tuesday -feira (22/11). “These are groups that have techniques to launder money, falsify documents, among other actions to maintain themselves”, he highlights.

The most common frauds, according to FenaSaúde, are forged ID cards, false requests for refunds for appointments and other procedures. However, in the Federal District, fraud regarding the use of orthoses and prostheses continues to be investigated, according to delegate Adriano Chaves Valente, director of the Division for Repression of Organized Crime of the Civil Police of the Federal District (Draco/PCDF).

“It is mainly practiced by orthopedists and surgeons, with the support of hospitals that overcharge procedures and even surgeries to harm health plans. explains the delegate.

To combat fraud, FenaSaúde is conducting its own investigations using artificial intelligence resources, including to investigate money laundering methods using cryptocurrencies. “Cryptocurrency is always used in that moment after the fraud, allowing the money to be used in a lawful way”.

The developments, however, depend on a modernization of the legislation. “Private corruption is not typified in Brazil. [Para facilitar punições] It would be necessary to have this law in the Penal Code. A new legislature is starting, who knows, maybe a bill will appear”, explains Glauce Carvalhal, legal director of the National Confederation of Insurance Companies.

*The reporter traveled at the invitation of FenaSaúde