The Brazilian healthcare system, both public and private, moves billions of reais every year. This volume of resources, combined with operational complexity, creates openings for fraudulent and corrupt practices that generate significant losses.
In the case of health plans, these losses do not remain merely on paper: they raise monthly fees, reduce the capacity for care, and, ultimately, harm the quality of the service offered to the patient.

The Cost of Frauds in Healthcare

According to estimates from industry entities, frauds and waste can represent between 10% and 25% of the annual revenue of operators.
In practice, we are talking about billions of reais wasted every year — amounts that could be reinvested in infrastructure, hiring professionals, or reducing premiums for beneficiaries.

Most Common Types of Frauds in Medical Orders in Brazil

1. Charging for procedures not performed
   Doctors, clinics, or hospitals register procedures or exams that were never actually performed but are charged to the plan.

2. Upcoding (inflating billing by code)
   Deliberate alteration of codes in the TUSS Table to classify simple procedures as more complex — and therefore, more expensive.

3. Unbundling (fragmented billing)
   Instead of charging a single package (which is cheaper), the provider splits the service into several separate charges to increase the final amount.

4. Excessive or unnecessary requests for tests
   Requests for tests that lack clinical justification, merely to generate revenue.

5. Misuse of credentials or membership cards
   When patients lend plan cards to third parties, often with the knowledge or participation of the provider.

6. Document fraud and tampering with medical records
   Changes to reports, dates, and signatures to justify charges or procedures.

7. Collusion between providers and suppliers
   Doctors and clinics may receive commissions or benefits from suppliers to prescribe unnecessary but high-value medications, prosthetics, or materials.

The Direct Impact on Plans and Patients

These practices generate unnecessary costs that accumulate rapidly.
For health operators, this means:

• Higher costs with claims (care costs)

• Lower operational margin

• Need for higher annual adjustments for beneficiaries

• Risk of financial imbalance and even insolvency

For the patient, the effects appear in the form of:

• More expensive plans

• Reduction of the accredited network

• Delays or restrictions on legitimate authorizations

• Less resources to invest in prevention and quality of care

How AI-Driven Auditing is Changing the Landscape

Traditionally, medical auditing is manual, slow, and expensive, which limits the volume of reviewed requests.
Today, AI tools can:

• Automatically read and interpret medical orders and documents

• Detect inconsistencies between reports, codes, and diagnoses

• Identify suspicious billing patterns

• Point out cases of potential fraud for faster human investigation

This automation dramatically reduces analysis time and allows operators to review nearly 100% of requests, rather than small samples.

The result:

• Significant savings in operational costs

• Prevention of fraud before payment

• More transparency and security for patients and plans

Conclusion

Frauds and corruption in the Brazilian medical sector are not just an ethical problem — they have a direct financial impact on everyone's wallet.
With intelligent auditing and the use of AI, it is possible to turn the tide, reducing waste, increasing efficiency, and ensuring that every real is invested in what truly matters: the health of the patient.