RIVIO MANIFESTO

THE BRAZILIAN SCENARIO

In a single generation, Brazil gained more than 15 years in life expectancy and reduced infant mortality nearly fourfold. Brazil has world-class medicine operating on top of an administrative infrastructure that would embarrass any other industry, permanently on the verge of collapse. While treatments advanced exponentially, the system that pays for, organizes, bills, and operationalizes those treatments remained frozen in time. And that gap is now extracting both a financial and clinical cost.

In 2025, private hospitals associated with ANAHP recovered 17% of their revenue through initial claim denials: amounts billed, delivered, and disputed by health insurers — a historic record. Most of those denials are eventually reversed: final denials settle around 2%. But the phrase "eventually" contains the entire problem. That "eventually" takes, on average, more than 80 days. And it forces hospitals to maintain an operational army dedicated to disputing, reconciling, justifying, and proving. All of that merely to receive money that was already owed.

The real cost, however, is not limited to claim denials. It also lies in underbilling: amounts hospitals were entitled to charge, but that disappeared inside the revenue cycle itself through inconsistent coding, manual processes, forgotten entries. In tests we conducted with clients, this underbilling ranges from 5% to 8% of total revenue. Unlike denied claims, that money never comes back. It was simply never billed.

When you combine claim denials, underbilling, and the operational cost of the endless patchwork required to sustain the system, what emerges is a structure designed to dissipate value. In 2024, according to ANAHP itself, 41.7% of hospitals invested less than they had planned. The consequence appears in the only place that matters: at the point of care.

This is not a lack of resources — the sector represents nearly 10% of GDP. It is a lack of coordination, technology, and the courage to recognize that hospital bureaucracy is not a natural phenomenon. It was built. And what was built can be dismantled.

This manifesto goes far beyond being a proposal. It is a diagnosis and a plan.

I. THE ANATOMY OF THE PROBLEM

1. Efficient hospitals save more lives. And the opposite is also true.

While clinical treatment has evolved exponentially over recent decades, hospital management has remained frozen in time, and this operational inefficiency has become the most underestimated silent mechanism of human impact in Brazilian healthcare. Every cent trapped in claim denials or lost to underbilling, every hour wasted on rework, every decision made in the dark is a cent, an hour, and a decision that failed to become a hospital bed, a medication, a nurse's salary, a functioning ICU.

When a hospital loses between 5% and 8% of its revenue because it is incapable of complying with the rules of hundreds of different insurance contracts, while simultaneously operating under 17% denial rates and payment cycles approaching 80 days, what is being described, technically, is a cash-compression machine. And compressed cash means less investment in clinical treatment, fewer beds, fewer healthcare professionals, and longer waiting times. The people who pay that price are those on the front lines: those who treat patients and those who receive treatment.

2. A hospital is a city. And it is being managed as if it were a store.

A large hospital coordinates dozens of critical departments in real time: ICU, surgical centers, emergency rooms, hospital pharmacy, laboratory, imaging, hospitality, laundry, building maintenance, security, HR, supply chain, billing, auditing. It operates 24 hours a day, 365 days a year, with overlapping teams, processes regulated by ANS and Anvisa, and clinical data that cannot be lost at any point in the chain.

Large private hospitals in Brazil maintain tens of thousands of direct employees while simultaneously managing contracts with dozens of insurers, each with its own pricing tables, deadlines, and rules.

This operation moves more per minute than many fintech companies. It carries more sensitive data in transit than many banks. And yet, across much of the sector, it is still managed through spreadsheets, legacy systems that do not communicate with each other, and manual processes dependent on the memory of whoever has been there the longest.

3. Clinical time is healthcare's scarcest resource — and we are burning it on forms.

Healthcare professionals spent a decade training to care for people. Today, a significant portion of their time is consumed sustaining an operational layer that should run autonomously: procedure coding, insurer justifications, account reconciliation, manual denial disputes, auditing forms.

Every clinical hour spent on bureaucracy is an hour that never existed for the patient. This is a system design problem. When the payment system requires exhaustive documentation as a condition for reimbursement, documentation becomes the primary job and the patient becomes residual activity.

Technology that returns this time to care is far more than administrative improvement. It is a clinical improvement. The distinction matters because it defines the success metric: not processing speed, but clinical hours recovered per patient treated.

4. The revenue cycle is structurally asymmetric. Hospitals need leadership to change the game.

The relationship between hospitals and health insurers is not symmetrical. Insurers concentrate power, with the five largest players controlling a significant portion of the market. They maintain legal departments specialized in disputes, operate with time on their side, and enforce pricing tables and rules that change unilaterally. Hospitals, in general, have overstretched billing teams, generalist legal departments, and deadlines working against them.

And this asymmetry begins before the first invoice is even issued: it begins in the contract itself. Pricing tables updated without notice. Clauses that support three simultaneous interpretations. Amendments that overwrite the main agreement. These contracts are instruments of extraction. Opacity keeps the asymmetry alive year after year.

The result of this imbalance is reflected in three numbers that speak for themselves. Initial denial rates rose from 7% in 2023 to 17% in the first quarter of 2025. At the end of the process, after all disputes are settled, only around 2% remain — meaning 88% of the original denials were unjustified from the start. And while these disputes continue, outstanding balances accumulate: rising from 50% to 62% of average monthly revenue between 2023 and 2024. The system operates like a compulsory loan: insurers withhold payment, hospitals contest, and the time in between becomes working capital.

But it would be dishonest to place all the blame on insurers. Part of the denials originate inside hospitals themselves. According to ANAHP, roughly 45% of entries in medical accounts are manually altered, deleted, or inserted. Operational errors, inconsistent coding, fragmented processes. Hospitals operate with one hand tied by market asymmetry and the other tied by their own internal fragmentation. Both need to be unlocked, and there is only one path that serves both sides: technology that makes processes more fluid, efficient, and transparent.

Without that stabilizing force in the middle, the war between insurers and hospitals will never end.

II. WHY EXISTING SOLUTIONS FAIL

5. Healthcare technology in Brazil was built to document the problem, not solve it.

Over the last decade, the Brazilian healthtech market built an entire industry of tools designed to make the wrong process faster. Billing systems that digitize claims submission. Hospital ERPs that merely record what already happened. Platforms that generate prettier reports about the same claim denials that continue to happen anyway.

Hospital management, especially in the revenue cycle, has always been treated in silos. Dozens of software systems handle different stages of the same process — authorization, coding, billing, auditing, appeals, reconciliation — without necessarily communicating with one another. The result is that errors that once happened on paper now happen digitally, spread across ten different interfaces, each with its own colorful dashboard designed to conceal the problem. Technically, this is the opposite of innovation.

6. The infrastructure the sector needs is a new operating system. Software alone will not solve the problem.

Making hospitals more efficient, better capitalized, and more capable of improving care quality requires an architectural rupture: replacing the manual, fragmented, reactive operational layer with an intelligence infrastructure that operates in real time, with autonomous execution and shared risk. The SaaS playbook of endlessly adding new features does not work in the sector's new reality.

That infrastructure has four inseparable components:

• AI capable of operating end-to-end processes — from coding to appeals — without depending on human approval at every step.

• Embedded operations with a human-in-the-loop structure that guarantees supervision, continuity, and continuous improvement within the institution, combining hospital process specialists and technology professionals into a single team.

• Real-time data that allows hospitals to understand their cash flow, denials, and contracts with the same precision with which they monitor their beds.

• Genuinely shared risk: the vendor only wins when the hospital gets paid.

III. RIVIO'S RESPONSE

7. Outcome guarantees are the only honest model for companies selling outcomes.

There is a specific pathology in the healthcare technology market: vendors selling denial reduction suffer no consequence when denials fail to decrease. The customer bears the outcome risk. The vendor collects the subscription fee regardless of the result.

This model is commercially unbalanced and fundamentally dishonest. If a company genuinely believes its technology solves the problem, it should be willing to be compensated for the outcome, not the promise. Refusing to guarantee results is a quiet confession of uncertainty about the solution itself.

8. Brazil has the world's most complex hospital revenue problem. That is why it will produce the world's most robust solution.

No other market combines, simultaneously, Brazil's regulatory heterogeneity, the scale of clinical and financial data generated by both the public and private healthcare systems — more than 50 million privately insured individuals alongside a public healthcare system serving over 200 million people — the density of insurers, and the absence of mature technological infrastructure.

Solving the problem here means solving it in hard mode. Whoever succeeds in this environment will emerge with technology capable of working anywhere else.

Added to this is an extraordinarily important cultural characteristic: the creativity to solve complex problems under constraint, and the rare ability to invent exits where others see only deadlock. What we are building in Brazil may become, within this decade, the model the world studies.

9. Healthcare needs engineers.

For decades, healthcare was treated as a question of more doctors, more beds, more consultants, more public policy. All of those things matter. But what is missing now is different, and few people in the sector are willing to say it out loud: healthcare needs engineers.

Engineers in the broadest sense: people who think about architecture, scale, systems, and how things work underneath the surface. People who look at a system with 17% recurring waste, payment cycles stretching across months, and unreadable contracts, and see what others do not: a badly designed system that can be redesigned.

Banks discovered over the last decade that technology had become their core competency or they would disappear. Retail discovered the same. Logistics, media, finance — all underwent the same transformation. Hospitals are now discovering that their core is also technology, and Brazilian healthcare needs a generation of engineers, data scientists, systems designers, and operators capable of treating hospital operations with the architectural seriousness they deserve.

Brazilian hospitals have greater operational complexity than banks while operating with a fraction of the engineering capacity. Analyzing the workforce composition of the country's 20 largest hospitals makes this evident. On average, only 4% of personnel are dedicated to engineering and information technology. And that is among the largest institutions in the country.

When both sides of the equation are combined, the sector is more than twenty times under-equipped in technical capacity. In no other critical sector of the country is this imbalance so severe, and in no other sector is the cost of delay measured in lives.

That is why our mission matters so much. We are building the infrastructure the sector never had — not just another software product. This infrastructure is being built by people who chose this problem as a mission for their lives, careers, and legacy to Brazil because they understand that solving it is the most important thing that can be done in technology this decade.

Conclusion

Brazilian healthcare will be transformed through technology. That is not up for debate. What is up for debate is whether this transformation will be led by people who deeply understand the problem or captured, once again, by those who learned how to profit from it.

We chose the first path. And we built a contractual guarantee to prove that we believe in it.

Efficient hospitals save more lives. Everything else is noise.