Fraudes contra cooperativas operadoras de plano de saúde médico: estudo dos riscos e dos controles internos

Abstract

Currently, frauds against organizations are countless and of some types, classifications and modalities. No company or entity can argue that it is immune to such attacks and assaults, including those which operate medical health insurance plans. In the field of supplementary health care, according to research performed by FENASEG (2007), in 2004, in a universe of two thousand interviewees, it was found that 34% have a propensity for fraud in medical health insurance plans. According to the ABRAMGE (2007), fraud has reached 20% of procedures covered by plans, both in terms of irregularities by clients as well as those who provide such services (doctors, laboratories and hospitals). In an attempt to investigate how risk analysis and internal controls may contribute towards prevention and identification of errors and frauds against medical health plan operators, within the methodological approach of a single case study, research was undertaken in which data collection tools were a questionnaire applied to the company's main managers, and intensive direct observation, as well as a review of bibliography and documents. Based on the results of this study, each macro-processed operational risks was examed andit has also been individually identified and measured. Afterwards an operational risk matrix was elaborated for this three main macro processes of the organization. It was found that the health plan operator in question represented, from a global average perspective, a relatively low operational risk of occurrence of mistakes and fraud (unlikely), but with the following consequences: high for the process of utilization of the plan by the client, average for the process of record alteration and low for the process of sale and registration of the new plan. It can be said that the risk analysis, through the use of risk matrix, becomes an important management tool for organization as well as fraud and erro prevention. It is therefore necessary to constantly follow up and analyze operational risk, as well as to permanently evaluate and update internal controls in such organizations.