ANS monitoring: what nurse auditors need to know

Professionals working in medical claims auditing should pay attention to the latest results of the Care Guarantee Monitoring released by Brazil’s National Supplementary Health Agency (ANS). The indicator directly affects payers’ relationships with plan members and providers and signals significant regulatory risks.

In the fourth quarter of 2024, the results showed that 540 payers were classified in Band 0, corresponding to the best performance, while 120 payers were placed in Band 3, the worst classification, associated with a higher risk of regulatory sanctions, such as the suspension of plan sales.

What is the Care Guarantee Monitoring?

It is an ANS oversight mechanism that assesses whether payers meet the maximum waiting times for appointments, tests and procedures, as established in ANS Normative Resolution No. 259/2011. The monitoring takes into account plan members’ care-related complaints and can result in measures such as fines, requirements for operational corrections and, in recurring cases, commercial restrictions.

When no provider is available within the regulatory deadline, the payer is required to offer alternatives, such as out-of-network care or reimbursement.

What changed starting in July 2024?

Following the 608th Meeting of the ANS Collegiate Board, on 07/01/2024, the monitoring model was improved. The main change was the adoption of a new database, broader and directly linked to actual complaints from plan members, replacing the previous model centered on internal oversight classifications.

The process began to focus more on coverage denials and failure to meet care deadlines, with manual analysis replaced by an automated model based on real unresolved requests. This increased accuracy in identifying care bottlenecks.

How does the classification of payers work?

Payers are distributed into bands according to their care performance. Band 0 indicates a low volume of complaints and better regulatory compliance. Band 3 represents a critical alert level. Remaining in this band for two consecutive cycles can result in penalties, including the suspension of sales of certain plans.

In the current cycle, despite the significant number of payers in Band 3, there is no immediate suspension yet, since the regulatory criterion considers two consecutive cycles.

Direct impacts on medical claims auditing

Payers classified in higher-risk bands tend to tighten their audit processes, stepping up denials, documentation requirements and review criteria. In this context, it is essential that auditors, especially nurse auditors, ensure that medical records, medical claims and care records fully comply with deadlines, contract coverage and clinical protocols.

The monitoring also works as an operational risk indicator. Providers that serve payers classified in Band 3 should strengthen internal controls to reduce financial and regulatory exposure.

A warning to auditors

The current scenario calls for a focus on three pillars: quality of the clinical record, robust documentation and anticipating inconsistencies in the medical claim. ANS monitoring reflects not only payers’ performance, but also the maturity of providers’ care and billing processes.

The auditor’s work is decisive for the financial sustainability, regulatory compliance and efficiency of the entire healthcare chain.

Technology as support for compliance

In a more stringent regulatory environment, the use of technology and artificial intelligence becomes strategic. Platforms such as Rivio support every stage of medical claims auditing, ensuring that the procedures performed are properly recorded, documented and billed.

For payers, automation enables systematic claim review, identification of inconsistencies and missing documentation, and the application of denials according to contract and regulatory rules. For providers, early electronic negotiation reduces rework, conflicts and financial losses, making the so-called “clean claim” possible.