Watch the December/2018 video on the subject:
Health plans: some points to note in your relationship with them:
POINT 1:
I don't work for health insurance plans. Here I explain why: click here
POINT 2:
Because fewer and fewer doctors work for health plans and more and more patients have problems with these plans:
🔗 https://drauziovarella.uol.com.br/drauzio/medicos-versus-planos-de-saude-artigo/
🔗 https://www.bbc.com/portuguese/noticias/2014/04/140407_saude_planos_mdb_dg
POINT 3:
What are your rights as a health insurance user (find out what they are so you can demand them)?
🔗 https://pt.slideshare.net/slideshow/oabms-cartilha-dos-usurios-de-sade-suplementar/12659426
POINT 4:
Complain if your rights have been violated! Find out how here:
- Suggestion: don't “accept” abuse or “let it go”, or it will continue to happen and could get worse and more frequent.
Request received by e-mail from a patient:
“Hi. Dr. Ícaro asked me for tests in two separate requests (radiological and laboratory). The plan to which I belong authorized the radiological exams, but vetoed the laboratory exams due to the excess. I spoke to the plan's expert and, in order to authorize them in full, I would need a medical report from Dr. Ícaro and then submit it to a medical board. That would certainly take a long time. So I think the most sensible thing would be to reduce the number of tests. As I recently went for a consultation, I assume you remember my medical condition. If possible, I think the most feasible thing would be for him to ask me again, restricting the tests to those that are essential for evaluation. I'll stop by the office to pick up the new request, if he agrees. Thank you.”
My comments:
1️⃣ No health insurance “expert”, “expert” or “auditor” can completely veto a request for tests without providing a plausible justification for this in writing. At most, the “expert” can veto the tests that he or she thinks that are not justified by the ICDs and diagnostic hypotheses presented in the request, but to simply act as the “colleague” in question did is illegal and goes against the provisions of the Code of Medical Ethics (and related resolutions), which clearly state that it is the attending physician who knows the patient's needs, and that the latter cannot have their instruments for the optimal practice of medicine curtailed, under any justification, for the benefit of the patient. And, by the way, each professional has their own needs and preferences when investigating a patient's case, in terms of what tests they need, what questions they deem necessary, among others. In other words, it is improper to issue the opinion of “tests requested in excess” when the expert certainly no has spent an hour with the patient in the office, getting to know the details of their history and exams before giving an opinion, and often has no interest in doing so.
2️⃣ The need for a “medical report” and a “medical board” is not justified by the above, and I see that many health insurance companies use this kind of “strategy” apparently to “beat the patient over the head”: when the person realizes how much bureaucracy they will have to deal with, they often prefer to give up their rights and do as the health insurance company wants or even give up on the tests. In this case, the situation is even better for the health plan, which “saves” money...
3️⃣ If the attending physician (who accompanies the patient) is the one who knows the patient's case and judges which tests are necessary to provide premium care, there is nothing “sensible” about reducing the number of tests requested just to meet the demands of someone who hasn't even analyzed the case with due attention, like the expert in question, would you agree? Furthermore, wouldn't the apparent “unreasonable excess of tests” just mean greater care for the patient and, therefore, more tests in order, with more data, to have a greater chance of correct diagnoses and offer better, more effective treatments?
4️⃣ What is “essential for evaluation”? Let's think about it: you can go on a trip in a VW Beetle or a Ferrari. One day you'll arrive at your destination, but how comfortably and at what speed will depend on the car you use, its state of repair, pre-trip checks... Who suggests the best factors similar to these when it comes to your health? Wouldn't it be your doctor?
5️⃣ The doctor-patient relationship has to be based on humanity, interest in the case, professionalism, technical knowledge, trust and common sense. When the health plan threatens any of these fundamentals, it is the plan that should be questioned, not the relationship. I therefore suggest going back to POINT 4 reported above.
My post on the subject from September 2014:
“Honestly, I think that some agreements (health plans) have a rather... schizophrenic:
Many patients say that they don't authorize some tests in the morning, but they authorize them “without problems” in the afternoon (or vice versa)... And, of course, it's always the same “good” health insurance companies, as you might have guessed.
I'll tell you all about it:
PATIENT (we all are at some point, aren't we?): know your rights and assert them!
Health insurance providers are thank you to justify denials of cover, in writing, to beneficiaries who so request - this is clear from the text below!
In other words, nationally: if your doctor orders tests, but the “health insurance company” refuses to pay for them, that “health” plan (some are even sickness plans) has the obligation to clearly state why they denied it, in writing! But do you know why they haven't done this? Because most people still don't ask for this justification in writing. I have patients within health plans who have confirmed this to me.
That's why I'm asking you to stand up for your rights and don't hesitate: when a health plan refuses to authorize exams or procedures for you, ask them in writing to justify the refusal!
I think it's absurd that, in times of protests and demonstrations (for less corruption and less abuse, right?), we allow those who often harm patients through neglect and unnecessary bureaucracy to pass unscathed. It's the doctor, dentist and/or nutritionist who knows what tests or procedures a patient needs!
Spread the word to as many people as possible, because I've seen that many just don't seem to know or care... Until something serious happens to the right that's been disrespected!”
My post on the subject from October 2013:
Three more “strange” (to say the least) agreements pickaxe, who just look for excuses to make life difficult for the patient, try to turn him against the doctor and/or make him give up the “work” of going for tests (to which he is entitled, since health is a universal right and we all pay an absurd amount each month for health insurance):
✅ “We do not accept orders with erasures” - when the “erasure” is just a scratch removing exams from a larger order.
✅ “The ICDs reported do not justify the number of tests requested” - By resolution of the CFM, we doctors shouldn't even include ICDs in requests, since including them exposes the patient's case (and thus their privacy). We only include them because, if we don't, the health insurance company won't authorize the requested tests - but this requirement goes against CFM guidelines, and the health insurance companies know this very well!
✅ Only deny exams by phone or in person, but never in writing - How agreements are obliged since the beginning of this year, they have taken advantage of the ignorance and/or comfort of most people, making the denials only verbally and claiming generic reasons, which are often absurd. The truth is that most people no ask for justification and file this request in writing! If you don't assert your rights, then, obliges to respect you, how do you expect to be respected when you really need them?
Finally, share this and stand up for your rights: no more abuses by health plans!
Author: Dr. Ícaro Alves Alcântara
Português do Brasil 
English 