Health plans and the CNJ: agreements to reduce litigation

Litigation in private healthcare is one of the phenomena that most affects the financial predictability of hospitals and payers in Brazil. According to the National Supplementary Health Agency (ANS), the number of complaints about coverage denials grew 374% over the last decade. Much of this volume turns into lawsuits that impose costs, uncertainty and rework on the entire chain.

In November 2024, the National Council of Justice (CNJ) and the ANS signed a technical cooperation agreement aimed at curbing this growth. Since then, new data and initiatives have been published, and the 2025 and 2026 landscape already makes it possible to assess what has changed and what is still under construction.

For hospital managers, understanding this dynamic is essential. Litigation directly affects the revenue cycle, increases the risk of denials and puts pressure on billing and audit teams.

What litigation in private healthcare is

Litigation in private healthcare occurs when a health plan member turns to the courts to obtain coverage for a procedure, medication or treatment the payer has denied.

When a physician prescribes something outside the ANS List of Health Procedures and Events (the Rol), the payer may deny coverage. The plan member then often goes to court.

The problem is that court decisions vary between courts and states. The same procedure may be authorized in São Paulo and denied in Rio Grande do Sul. This asymmetry creates instability for payers, hospitals and patients.

For hospitals, the impact is twofold: on one side, pressure to perform court-ordered procedures, often with no guarantee of payment; on the other, the risk of a denial when the payer disputes the charge for lack of contractual coverage.

What the CNJ-ANS agreement says

On November 21, 2024, during the 3rd Congress of the National Judiciary Forum for Health (Fonajus) in São Paulo, the CNJ and the ANS signed a technical cooperation agreement with three central goals:

1. prevent new lawsuits through early technical guidance;

2. speed up the judgment of existing cases;

3. provide judges with technical and scientific input.

The most concrete instrument is the integration of the ANS into e-NatJus, the CNJ platform that gathers technical opinions to support court decisions in healthcare. Until then, the system had been geared almost exclusively to public health.

With the agreement, the ANS itself began funding the technical notes that will guide decisions in private healthcare.

The 2025 and 2026 landscape: what the data show

The Diagnosis of Health Litigation, published by the CNJ in partnership with UNDP in 2025, provides the most complete picture of the problem to date. The study analyzed data from August 2024 to July 2025 and revealed a landscape of high litigation with very little consensual resolution.

During the period, 123,000 new cases related to private healthcare were filed in state trial courts. The total backlog of pending cases in the country reached 895,000, with São Paulo accounting for almost 93,000 cases in the state courts alone.

The rulings in favor of plan members are significant: 69.5% of injunctions were granted and 87% of lawsuits were ultimately decided in favor of the plan member. Conciliation, on the other hand, is consistently low in every court.

For 2026, Fonajus set the goal of expanding conciliation and adding specific health indicators to the courts’ National Goals, with direct dialogue with the ANS to develop an e-NatJus module focused on private healthcare.

How litigation affects hospitals

For hospitals, litigation is a financial risk that runs through the hospital’s revenue cycle from end to end.

When a patient obtains an injunction to undergo a procedure, the hospital is required to perform it, but coverage by the payer is not guaranteed. If the procedure is not in the contract or on the ANS Rol, the payer may deny the charge even after the court decision, citing lack of contractual coverage. The hospital is caught in the middle of the conflict: it provided the care but is not sure it will be paid.

There is also the impact on billing and audit teams. Court-ordered procedures require specific documentation, careful coding and follow-up of the case. Any failure along the way increases the risk of a technical or administrative denial.

Finally, the unpredictability of court-ordered demands makes financial planning difficult. The hospital does not know in advance which procedures will be requested through the courts, which complicates the management of capacity, inventory and contracts with payers.

What hospitals can do to protect themselves

The most effective protection against the effects of litigation starts with a well-documented operation and solid prospective audit processes.

The first step is to maintain rigorous clinical documentation in every patient encounter, especially high-complexity ones. Complete medical records, well-grounded reports and detailed care records are the main argument both for getting authorizations approved and for appealing denials.

The second point is systematic monitoring of coverage denials. Identifying refusal patterns by payer, by procedure or by ICD code makes it possible to anticipate conflicts, renegotiate contracts and guide the medical team on how to document clinical indications more effectively.

Finally, automating the revenue cycle reduces coding errors and ensures that each procedure reaches the payer with all the information needed to avoid denials and disputes. Hospitals that run on manual processes are more vulnerable to inconsistencies that, in a litigation context, turn into financial liabilities.

FAQ - frequently asked questions about health litigation

What is the ANS List of Procedures?

It is the list of procedures, tests and treatments that all private health plans in Brazil are required to cover. Updated periodically by the ANS, the Rol sets the minimum contractual floor. Procedures outside it may be denied by payers, which often leads to lawsuits.

What is e-NatJus and how does it work in private healthcare?

e-NatJus is the CNJ platform that gathers scientific technical notes to support court decisions in healthcare. Until November 2024, it was focused mainly on public health. With the CNJ-ANS agreement, the ANS began funding technical notes specific to private healthcare, expanding technical support for judges in this area.

How does the CNJ-ANS agreement directly affect hospitals?

Indirectly, but in a relevant way. Court decisions that are better grounded technically tend to be more predictable, which reduces uncertainty for hospitals that perform procedures under court order. The expectation is that, with stronger technical input, fewer injunctions will be granted for procedures without scientific or contractual support.

What can the hospital do when a procedure is denied by the health plan?

The administrative route should be the first step: filing an ANS Preliminary Intermediation Notice (NIP), which makes it possible to resolve the conflict without going to court. If there is an unjustified denial, the hospital can support the plan member with technical documentation to ground an appeal or a lawsuit. In parallel, it is advisable to record the history of denials by payer to identify patterns and renegotiate contracts.