Although it is a collective benefit, each user's individual actions have a direct impact (for better or for worse) on how their health insurance plan is sustained.
Well, this question can be answered with a few different reasons. But before diving into each one, we need to start with the basics: understanding how health insurance works.
Behind the plan provided by your company is the health insurance provider. This provider maintains the benefit and, by partnering with a network of approved clinics, hospitals, and professionals, offers the services requested by the beneficiary (you). This means that by making well-informed decisions when using the plan, you help ensure it keeps the same quality, contribution rates, and so on.
Did you know that healthcare costs are the second largest expense for companies, right after payroll? So, misusing health insurance not only represents a huge waste of resources but also threatens the financial balance of your employer!
Aside from certain fraudulent actions — which we'll discuss shortly — the consequences of irresponsible use aren't limited to just the person responsible. When someone disrupts the balance of the plan, that imbalance is often felt by all users.
A conscious use of health insurance goes beyond just the bureaucratic side. In other words, understanding that a culture of health prevention is part of this awareness means investing in deeper aspects like well-being, quality of life, and longevity.
Basically, by protecting it from the greatest threat to any health plan: the uncontrolled rise of the claims ratio.
This intimidating term simply refers to the relationship between the costs of medical and hospital care—essentially, the health services used by plan beneficiaries—and the revenue of the health insurance provider. The result of this calculation is called the claims ratio. So far, so good. After all, the claims ratio is natural in any insurance plan, and by itself, it isn't a bad thing. The problem is when it spirals out of control.
Here's why: when total spending exceeds the amount the company pays to the provider, there’s a risk, for instance, of challenges in the next contract negotiation, which may result in:
Adopting or increasing coinsurance (the contribution paid each time the health plan is used)
Switching to a more limited network plan (downgrade)
Or even canceling the plan
Here are the main behaviors that threaten the balance of the plan or cause the claims ratio to spike:
Using the ER without real need, whether because it's not a true emergency or just to get a sick note, not only takes a spot from someone in real need but also results in a much higher cost than a regular consultation—for both you and everyone in the company.
If you need follow-up or exam review, be sure to return to the doctor within the set time frame. This prevents an extra consultation from being billed, saving unnecessary expenses.
Never sign blank forms. And when they’re filled out, make sure the services listed are only those you actually used.
In cases where surgery is denied by the plan, some doctors might suggest pushing it through the ER or altering the patient’s medical report. These actions are fraudulent!
Reimbursement isn't a cash machine! If someone offers to increase it by splitting the consultation fee into two or more receipts, decline. This is fraud, and the insurance provider may take legal action against you and your employer.
Lending your insurance card or allowing someone to assume your identity to use it not only increases costs for everyone—since someone outside the plan is using it—but could also result in plan cancellation, as this practice is illegal.
Health insurance is both cause and effect. By using it wisely and avoiding the chain reaction of factors that threaten it, you help keep in place the structure that protects the most valuable asset of any beneficiary: health.
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Technical Manager: Dr. Sérgio Hércules CRM 61.605
