Content/ Rivio Manifesto
Efficient hospitals save more lives.
Brazil has world-class medicine running on an administrative infrastructure that would embarrass any other industry. This manifesto is more than a proposal: it is a diagnosis and a plan.
- By
- Rivio, Editorial team
- Published
- Reading time
- 10 minutes
The landscape
The Brazilian landscape
In a single generation, Brazil gained more than 15 years of life expectancy and cut infant mortality by more than 70%. Brazil has world-class medicine running on an administrative infrastructure that would embarrass any other industry, on the verge of collapse. While treatments advanced exponentially, the system that pays for, organizes, bills and operates those treatments stood still. And the gap is taking a financial and clinical toll.
In 2025, the private hospitals that belong to ANAHP had 17% of their billing sent back as initial denials — amounts billed, delivered and disputed by health plans — an all-time record. Most of those denials are, in the end, reversed: the final denial rate is around 2%. But the phrase “in the end” carries the whole problem. That “end” takes, on average, more than 80 days. And it costs the hospital an operational army dedicated to disputing, reconciling, justifying and proving. All of it just to receive what was already owed.
-
17%
Of billing sent back as initial denials, in 2025
-
2%
Is what remains of denials after all the disputes
-
80 days
The average time between a denial and its reversal
-
5% to 8%
Of revenue lost to underbilling, which never comes back
The real price, however, is not only in denials. It is also in underbilling: amounts the hospital was entitled to bill but that got lost inside its own cycle, in inconsistent coding, manual processes and forgotten charges. In tests we have run with clients, this underbilling ranges from 5% to 8% of billing. Unlike a denial, this money does not come back. It simply was never billed.
Adding up denials, underbilling and the operational cost of the endless firefighting that holds it all together, what you are looking at is a system designed to dissipate value. In 2024, according to ANAHP itself, 41.7% of hospitals invested less than they had planned. The consequence shows up in the only place that matters: at the point of care.
It is not a lack of resources. It is a lack of coordination, of technology and of the courage to admit that hospital bureaucracy was built.
Part I/ The anatomy of the problem
Efficient hospitals save more lives. And the opposite is also true.
While clinical treatment has evolved exponentially over recent decades, hospital management stood still, and that operational inefficiency is the most underestimated silent driver of human impact in Brazilian healthcare. Every real stuck in denials or lost to underbilling, every hour spent on rework, every decision made in the dark is a real, an hour and a decision that never became a bed, a medication, a nurse’s salary, a working ICU.
When a hospital fails to collect between 5% and 8% of its revenue because it is impossible to follow every rule of hundreds of different health plan contracts, and still operates with 17% denials and payment times of nearly 80 days, what is being described, technically, is a cash-squeezing machine. And squeezed cash means less investment in clinical treatment, fewer beds, fewer healthcare professionals and more time on the waiting list. Those who pay the price are on the front line: the people who treat patients and the people who receive treatment.
A hospital is a city. And it is being run like a store.
A large hospital coordinates dozens of critical departments in real time: ICU, operating rooms, emergency, hospital pharmacy, laboratory, imaging, hospitality, laundry, building maintenance, security, HR, procurement, billing, auditing. It operates 24 hours a day, 365 days a year, with teams overlapping across shifts, processes governed by ANS and Anvisa rules, and clinical data that cannot be lost at any point in the chain.
Large private hospitals in Brazil keep tens of thousands of direct employees and simultaneously manage contracts with dozens of health plans, each with its own price tables, deadlines and rules.
This operation has more activity per minute than many fintechs. It has more sensitive data in transit than many banks. And still, across much of the industry, it is run on spreadsheets, legacy systems that don’t talk to each other and manual processes that depend on the memory of whoever has been there the longest.
Clinical time is healthcare’s scarcest resource, and we are burning it on forms.
Healthcare professionals spent a decade of study learning to care for people. Today, a significant share of their time is consumed propping up an operational layer that should run on its own: procedure coding, justifications for health plans, claim reconciliation, manual denial appeals, audit 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 extensive documentation as a condition of payment, documentation becomes the main job and the patient becomes the residual activity.
Technology that gives this time back to care is much more than an administrative improvement. It is an improvement in care. The distinction matters because it defines the measure of success: not processing speed, but clinical hours recovered per patient seen.
The revenue cycle is structurally asymmetric. Hospitals need leadership to turn the tables.
The relationship between hospitals and health plans is not symmetric. Health plans concentrate power, with the five largest controlling a significant share of the market; they have legal departments specialized in disputes, time on their side, and they operate with price tables and rules that change unilaterally. Hospitals, in general, have a generalist legal team, an overloaded billing team and deadlines running against them.
And this asymmetry starts before the first invoice: it starts in the contract. Price tables that update without notice. Clauses that allow three interpretations at once. Amendments that override the main body. These contracts are instruments of capture. Opacity keeps the asymmetry alive, year after year.
The result of this asymmetry shows in three numbers that speak for themselves. Initial denials rose from 7% in 2023 to 17% in the first quarter of 2025. In the end, after all the disputes, only about 2% hold up, which means 88% of initial denials were unwarranted from the start. And while those disputes run, open balances pile up: they went from 50% to 62% of average monthly billing between 2023 and 2024. The system works like a compulsory loan: the health plan withholds, the hospital disputes, and the time in between is working capital.
But it would be dishonest to blame only the health plans. Some denials originate inside the hospital. According to ANAHP, about 45% of entries on medical claims are changed, deleted or entered manually. Operational errors, inconsistent coding, fragmented processes. The hospital operates with one hand tied by the market’s asymmetry and the other by its own internal fragmentation. Both need to be freed, and there is only one path that serves both sides: technology that makes processes smoother, more efficient and more transparent.
Without that peacemaking force in the middle, the war between health plans and hospitals will never end.
Every clinical hour spent on bureaucracy is an hour that never existed for the patient.
Part II/ Why the solutions fail
Healthcare technology in Brazil was built to document the problem, not to solve it.
Over the last decade, the Brazilian healthtech market has built an entire industry of tools that make the wrong process faster. Billing systems that digitize claim submission. Hospital ERPs that record what happened. Platforms that produce prettier reports about the same denials that keep happening.
Hospital management, especially in the revenue cycle, has always been handled in silos. There are dozens of software products for different stages of the same process — authorization, coding, billing, auditing, appeals, reconciliation — that don’t necessarily talk to each other. The result is that the errors that used to happen on paper now happen in digital form, spread across ten different interfaces, each with its own colorful dashboard to hide the problem. That is, technically, the opposite of innovation.
The infrastructure the industry needs is a new operating system. Software alone does not solve the problem.
Making hospitals more efficient, with more cash and the capacity to improve the quality of care, requires an architectural break: replacing the manual, fragmented and reactive operating layer with an intelligence infrastructure that runs in real time, with autonomous execution and shared risk. The SaaS playbook of continuously adding features does not work in the industry’s new reality.
This infrastructure has four inseparable components. First, AI that runs processes end to end, from coding to appeals, without depending on human approval at every step. Second, an embedded operation with human in the loop that ensures supervision, continuity and continuous improvement inside the institution, with hospital process specialists and technology professionals working as a single team. Third, real-time data that lets the hospital see its cash, its denials and its contracts with the same precision with which it sees its beds. Fourth, and most important: genuinely shared risk — the vendor only wins when the hospital gets paid.
Part III/ Our proposal
A results guarantee is the only honest model for anyone who sells results.
There is a specific pathology in the healthcare technology market: the vendor that sells denial reduction suffers no consequence when denials don’t go down. The risk of the outcome stays with the client. The vendor pockets the monthly 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 paid for the result, not for the promise. Refusing to guarantee is a veiled confession of uncertainty about its own solution.
Brazil has the most complex hospital revenue problem in the world. That is why it will produce the most robust solution.
No other market combines, at the same time, Brazil’s regulatory heterogeneity, the volume of clinical and financial data from SUS and private healthcare (more than 50 million private plan members, on top of a population of more than 200 million in SUS), the density of health plans and the absence of mature technology infrastructure.
Solving it here is solving it on hard mode. Whoever gets through this comes out with technology that works in any other market.
To this we add a hugely important cultural trait: creativity to solve complex problems under constraint, and the rare ability to invent a way out where others see a dead end. What we are building in Brazil may become, this decade, the model the world will study.
Healthcare needs engineers.
For decades, the healthcare industry was thought of as a matter of more doctors, more beds, more consultants, more public policy. All of that matters. But what is missing now is different, and few in the industry allow themselves to say it out loud: healthcare needs engineers.
Engineers in the broad sense: people who think in architecture, in scale, in systems, in how things work underneath. People who look at a problem with 17% recurring waste, deadlines that stretch for months and unreadable contracts, and see what others don’t: a badly designed system that can be redesigned.
Over the last decade, banks discovered that their core had to be technology or they would disappear. Retail discovered the same. Logistics, media, finance. They all went through the same shift. Hospitals are now discovering that their core is also technology, and Brazilian healthcare needs a generation of engineers, data scientists, systems designers and operators who treat hospital operations with the architectural seriousness they deserve.
Brazilian hospitals have greater operational complexity than banks and operate with a fraction of the engineering capacity. Looking at the workforce of Brazil’s 20 largest hospitals makes this clear. On average, only 4% of people are dedicated to engineering and information technology. That is at the largest hospitals in the country; imagine the rest, outside the big cities.
Putting both ends together, the industry is more than twenty times under-equipped in technical capacity. In no other critical sector in the country is this disproportion so large, and in no other is the cost of delay paid in lives.
That is why our mission matters so much. We are building the infrastructure the industry never had, not just another piece of software. It is being built by people who chose this problem as a life mission, a career and a legacy for Brazil, because they understand that solving it is the most important thing anyone can do in technology this decade.
Conclusion
Conclusion
Brazilian healthcare will be transformed through technology. That is not up for debate. What is up for debate is whether that transformation will be led by those who deeply understand the problem or captured, once again, by those who learned to profit from it.
We chose the first path. And we built the contractual guarantee to prove that we believe in it.
Efficient hospitals save more lives. The rest is noise.
