FAILURES IN AUDITS AND MEDICAL BOARDS IN THE EVALUATION FOR SPINE SURGERY AUTHORIZATION IN BRAZIL

FALHAS EM AUDITORIAS E JUNTAS MéDICAS EM AVALIAçõES PARA LIBERAçãO DE CIRURGIA DE COLUNA NO BRASIL

FALLAS EN LAS AUDITORíAS Y JUNTAS MéDICAS EN LAS EVALUACIONES PARA LA AUTORIZACIóN DE CIRUGíAS DE COLUMNA EN BRASIL

ABSTRACT

Objective:  The audit and medical board in surgeries focuses on the evaluation and adequacy of surgical procedures. The objective was to compare whether the evaluations were in line with the resolutions of the Federal Council of Medicine (CFM) and the standards of the National Health Agency (ANS) in conducting audits for the release of spinal surgical procedures.

Methods:  The research was conducted through document analysis of the results of audits and medical boards for the evaluation and release of surgical procedures in neurosurgery and spinal surgery.

Results:  A total of 55 audits were evaluated. The most frequent failures on the part of the audit were the denial of material in 49 audits (89.09%) and the denial of procedure in 46 audits (83.63%), which effectively vetoed the procedure.

Conclusion:  The failures identified in the audits and medical boards of surgeries can compromise the impartiality and quality of the audit process. These failures can lead to an increase in complaints from health insurance companies to other regulatory agencies. Level of Evidence IV; Economic and Decision Analysis.

Keywords:
Medical Audit; Health Plans; Spine

RESUMO

Objetivo:  A auditoria e junta médica em cirurgias se concentra na avaliação e adequação dos procedimentos cirúrgicos. O objetivo foi confrontar se as avaliações iam de encontro as resoluções do Conselho Federal de Medicina (CFM) e das normas da Agência Nacional de Saúde (ANS) na realização de auditorias para liberação de procedimentos cirúrgicos de coluna.

Método:  A pesquisa foi realizada através de análise documental dos resultados de auditorias e juntas médicas para a avaliação e liberação de procedimentos cirúrgicos em neurocirurgia e cirurgia de coluna. Resultado: Um total de 55 auditorias foram avaliadas. As falhas mais frequentes por parte da auditoria foi a negativa de material em 49 (89,09%) e as negativas de procedimento, em 46 das auditorias (83,63%) vetando o procedimento.

Conclusão:  As falhas identificadas nas auditorias e juntas médicas de cirurgias podem comprometer a imparcialidade e a qualidade do processo de auditoria. Essas falhas podem levar a um aumento das reclamações das operadoras de saúde em outros órgãos reguladores. Nível de evidência IV; Análise Econômica e de Decisão.

Descritores:
Auditoria Médica; Planos de Saúde; Coluna Vertebral

RESUMEN

Objetivo:  La auditoría y junta médica en cirugías se centra en la evaluación y adecuación de los procedimientos quirúrgicos. El objetivo fue comparar si las evaluaciones estaban en línea con las resoluciones del Consejo Federal de Medicina (CFM) y los estándares de la Agencia Nacional de Salud (ANS) al realizar auditorías para la liberación de procedimientos quirúrgicos de columna.

Método:  La investigación se realizó a través del análisis documental de los resultados de auditorías y juntas médicas de evaluación y liberación de procedimientos quirúrgicos en neurocirugía y cirugía de columna.

Resultados:  En total se evaluaron 55 auditorías. Las fallas más frecuentes por parte de la auditoría fueron la denegación de material en 49 (89,09%) y la denegación de procedimiento, en 46 de las auditorías (83,63%) vetando el procedimiento.

Conclusiones:  Las fallas identificadas en las auditorías quirúrgicas y en las juntas médicas pueden comprometer la imparcialidad y la calidad del proceso de auditoría. Estas fallas podrían provocar un aumento de quejas de las compañías de seguros de salud ante otros organismos reguladores. Nivel de Evidencia IV; Análisis Económico y de Decisiones.

Descriptores:
Auditoría Médica; Planes de Salud; Columna Vertebral

INTRODUCTION

The audit and medical board is a systematic process for reviewing and evaluating medical practices to ensure the quality and safety of patient care.¹,² It involves analyzing medical data and records, as well as reviewing the procedures and protocols adopted by health professionals.³,⁴ Medical audit can be carried out both internally, by dedicated teams within health institutions, and externally, by companies specializing in health audits.⁵

The main purpose of the medical audit is to identify and correct possible discrepancies, errors or failures that could compromise the quality of care and patient safety.⁴,⁶,⁷ It also seeks to promote the continuous improvement of medical processes and practices, as well as to ensure compliance with the standards and guidelines established by the regulatory bodies.⁸,⁹

Medical audit in surgeries is a specific area of medical audit that focuses on the review and evaluation of surgical procedures. It covers from preoperative analysis to postoperative follow-up, to ensure that all stages of the process are carried out per established standards and protocols.¹⁰

During medical audits in surgeries, various aspects are analyzed, including the surgical indication, patient informed consent, preoperative preparation, the execution of the procedure itself, patient monitoring during surgery, and postoperative follow-up.¹⁰-¹³ In addition, medical records, complementary examinations, medications used, and other details relevant to the evaluation of the procedure are observed.¹¹,¹⁴ With this, the audits and medical boards aim to ensure that professionals are properly trained and up-to-date about the best practices and technological advances in the surgical area, also assisting in the economic viability of the entire health structure.¹⁴-¹⁶

However, not all audits and medical boards of spinal surgery are carried out impartially and objectively. In some cases, arbitrary acts are committed during these evaluations, which can have negative consequences for both the professionals and patients involved.

One of the most common failures in medical audits of surgeries is the lack of impartiality on the part of auditors and board doctors.¹⁷ In some cases, auditors may have personal or financial interests that can influence the evaluation of the procedure. This can lead to a tendency and unfair analysis, compromising the integrity of the audit process. Another possible failure that may occur in the medical audits of surgeries is the lack of scientific foundation in the decisions and assessments made by the auditors.

These failures lead to an increase in complaints from healthcare operators to the National Health Agency (ANS) and other relevant bodies. Complaints are generally related to the duality in conducting examinations, consultations, and treatments. But a portion of these complaints is due to negative outcomes in surgical procedures. This growing increase can be observed through media reports.¹⁸-²³

OBJECTIVES

The study aims to evaluate the main failures in the audits and medical boards in supplementary health in the face of the Code of Medical Ethics, resolutions of the Federal Council of Medicine (CFM) and the standards of the National Agency of Health (ANS) in conducting medical audits for the evaluation and release of spine surgery in Brazil.

METHODS

Research site

The research was conducted through a documentary analysis of audit results and medical journals, which were obtained for the evaluation and release of surgical procedures in spine surgery, and were sent via email. The results of audits and boards were forwarded by email by neurosurgeons and orthopedists who were registered with the Brazilian Society of Neurosurgery (https://encontreseumedico.neurocirurgia.org.br/) and the Brazilian Spine Society (https://www.encontreseumedico.coluna.com.br/). The survey invitation was sent to the participants who submitted the information spontaneously. As there was no identification of participants and no clinical intervention and to follow by the Standards and Guidelines for Research Involving Human Beings (Resolution CNS 466/2012) and Resolution CNS 510/2016, in addition to considering the principles of the Helsinki Declaration of the World Medical Association (1964 and subsequent reformulations, before 2008), in addition to meeting the specific legislation of the country where the research was developed there was no need to submit to the ethics committee.

Identification of sources and research material

The information was analyzed and tabulated in a manner that made it impossible to identify the doctors, operators, companies, and patients. Operators were numbered from 1 to 12, and auditors and board doctors from 1 to 22.

The decisions of the audits and committees were analyzed based on the Code of Medical Ethics, Standards, and Resolutions of the Federal Council of Medicine and the National Health Agency.

General characteristics of the study population

The results, audits, and medical boards were selected based on documents received via email. They should include known desirable information, such as: the name of the auditor, doctor, or board, the company responsible for the audit or board, procedures requested, materials requested, negative and technical-scientific basis of the audits, and the legislation used.

Inclusion and exclusion criteria

The results of audits and medical boards regarding spine surgeries received from July to December 2023 were included in the survey.

Judgments that were excluded from the study were:

a. do not have all the data necessary for analysis, and

b. refer to other medical specialties and treatments.

Research targeting

The responsible researcher conducted the analysis and data collection to select the desired audit results for this study. The inclusion and exclusion criteria were applied.

The information from the audit results was transcribed into a previously prepared table to collect the data. The questionnaires were organized in chronological order. The information in the questionnaires was tabulated and inserted into the Excel 365® software. The database was constructed to verify the reality of Brazil on the subject in 2023.

RESULTS

Characteristics of Audits

A total of 58 audits were received, with three excluded due to a lack of data for proper analysis. A total of 55 audits were evaluated, and simple comparisons were made between the information collected and the averages for analysis.

A total of 55 audits and medical boards were analyzed in response to requests for surgical procedures. Twelve healthcare operators would be responsible for the cost of the surgical procedures. Operator 9 was the one that had the most surgeries requested, with 17 (30.90%) in total (Figure 1), with an average of 4.58 surgical requests per operator. The rest obtained the following audit result: Operator 1 with 6 (10.90%), Operator 2 with 3 (5.45%), Operator 6 with 3 (3.63%), Operator 8 with 8 (14.54%), Operators 10 and 12 with 7 (12.72%) each and Operators 3, 4, 5, 7 and 11 with 1 (1.81%) each. (Figure 1)

Figure 1
Number of audits by identified operators.

Of the evaluations for the release of surgeries, 15 (27.27%) were initial audits, and 40 (72.72%) were medical boards or third opinions (Figure 2). When evaluating those responsible for the audit, whether the agreement itself or a third-party company, it was found that 2 (3.63%) audits were carried out by the Company 1, 41 (74, 54%) by the Company 2 and 12 (21.81%) by the healthcare provider itself. (Figure 3)

Figure 2
Number of audits and their separation between initial audits and medical boards (third opinion).

Figure 3
Number of audits by companies responsible for the process.

Of the auditors, 22 medical auditors were identified, while six audits did not have a responsible auditor (identified). Consequently, each medical auditor was responsible for an average of 2.23 audits. However, only Medical Auditor 4 was responsible for 8 (14.54%) audits. The Medical Auditors 1, 3, 5, 7, 8, 10, 11, 14, 15, 18, 19, 20 and 21 were responsible for 1 (1.81%) audit each, the Medical Auditors 9, 12, 16, 17 were responsible for 3 (5.45%), the Medical Auditor 2 was responsible for 4 (7.27%) audits, the Medical Auditor 6 and 13 for 5 (9.09%) audits and the Medical Auditor 22 for 2 (3.63%) audits. (Figure 4)

Figure 4
Number of Board Medical and Medical Auditors by audits carried out.

Identified flaws

Of the 55 audits performed, it was possible to identify the following failures: material refusal, procedural or codification refusal, attempt to modify the surgical technique, audit doctor or board registered with the Regional Council of Medicine of another state, total procedure refusal, absence of adequate scientific basis, audit company registered with the Regional Council of Medicine of another state and absence of the identification of the auditor or board doctor.

The audits and board with refusal to use some of the materials requested by the surgeon physician are identified in Figure 5.

Figure 5
Defects identified in the results of audits.

Negative material was present in 49 (89.09%) of the total audits and boards evaluated. In two cases (3.63%), the assisting physician was required to perform the replacement of the surgical material (interference in the material branding).

Negatives of the procedure (code of medical fees) occurred in 46 of the audits (83.63%). The total negative outcome of the procedure (in terms of codes and materials) was verified in 14 cases (25%, 45%), i.e., cases in which the surgery was completely contraindicated by the audit or medical board. In 9 (16.36%), there was even an indication of changing the surgical technique.

In 6 audits (10.90%) carried out and sent to the surgeon, the doctor requesting the procedure did not present the auditor’s identification. The cases in which the auditor or board doctor was not registered in the regional council of medicine where the audit was carried out corresponded to 37 of the cases (67.27%). The company responsible for the audit in 42 of the cases (76.36%) also did not have a register in the medical council where it was operating. On the technical-scientific basis, in 55 (100%) of the cases, there was no basis or the information was poorly informed.

DISCUSSION

The audit and medical board is a fundamental activity to ensure the quality and efficiency of the health services provided to patients.²⁴,²⁵ It plays a key role in the management of health services, bringing various benefits to institutions and their patients, such as guaranteeing the quality of services, ensuring compliance with standards and regulations, identifying problems and opportunities for improvement, controlling costs and resources, and improving communication between professionals.⁴,²⁶

The medical audit and the board should be based on specific principles and techniques to ensure the effectiveness and impartiality of the evaluation.²⁷ Some of these principles are independence and impartiality, reliability and confidentiality, updating and training, and effective communication with health professionals.⁷ However, in the audits evaluated, several of these principles appeared to have been violated when we applied the recommendations of the Medical Ethics Code, CFM, and ANS Standards and Regulations.

Surgical procedures and medical treatments are not always covered by health plans, which can lead to differences in coverage between health professionals and operators. In these cases, medical audits and committees play a key role in assessment and decision-making.²⁸ They should help prevent abuses by healthcare professionals and plan operators by ensuring that patients receive the appropriate and necessary treatment.⁹

Medical committees are committees formed by healthcare professionals, typically comprising a doctor or assistant dentist, a representative of the healthcare plan operator, and a third professional chosen by mutual agreement among the parties involved.²⁹ They are triggered when there are disagreements between the applicant professional and the operator regarding the need for a particular procedure, examination, or treatment.²⁸ In this work, 15 (27.27%) were initial audits and 40 (72.72%) would be medical boards or third opinions, but all the analyses showed some sort of disagreement with what was requested by the assistant physician.

The primary function of medical boards (or third opinions) is to analyze, impartially and technically, the requests made by assisting professionals and to assess whether they are necessary and appropriate for the patient’s treatment. This assessment aims to ensure the quality of care, prevent fraud, and ensure that the resources are used appropriately.²⁸ However, all of the audits and boards analyzed had some kind of objection from the patient or surgeon.

It is common knowledge that medical boards contribute to saving healthcare system resources by avoiding the implementation of unnecessary or inappropriate procedures.³⁰,³¹ This is especially important in a context where the resources are limited and it is necessary to ensure access to all patients who need healthcare services. However, an excessive pursuit of savings can lead to harm, leaving patients without the necessary care.

The medical board aims to thoroughly analyze all information and documents related to the case in question. The professionals involved in the board conduct a thorough assessment, taking into account clinical, technical, and scientific aspects. However, in virtually all the audits and boards analyzed in this paper, there were divergences, and in all of them, there was no adequate technical-scientific basis to justify these divergences.

It is essential to note that the medical board does not apply to procedures that require prior authorization from the operator. It can be summoned in any situation where there is clinical divergence about the indication performed by the assisting physician. Therefore, a practice that is increasingly common in the supplementary healthcare system, especially during periods when the economic balance of healthcare operators is becoming increasingly difficult.

The formation of the medical board follows a pre-established process. The assisting physician is responsible for representing the recipient and presenting their justification for the procedure or treatment. The health plan operator, in turn, also indicates a professional to compose the medical board. It is important to note that the third member of the medical board is chosen by mutual agreement between the parties. This professional third party is fundamental to ensuring impartiality and fair decision-making.

During the analysis, information such as the patient’s diagnosis, the severity of the condition, the effectiveness of the proposed treatment, and the need for special materials, among other relevant factors, is considered. From these analyses, the medical board members reach a consensus and issue a technical opinion.

In the survey, all auditors and board doctors are affiliated with the healthcare provider or third-party company providing the audit service. A single company was responsible for 74.54% of the audits, and only 22 medical auditors were responsible for 55 audits, with a single one responsible for 14.54% of them. Therefore, there is a suspicion that the medical board’s impartiality is compromised.

However, in addition to not finding the technical basis in all the audits of the study, various procedures and materials were denied. Of the procedures, there were negative surgical materials in 89.09%, procedural codes in 83.63%, and a total of negative results (of all materials and procedures) in 25.45%. In addition, 83.63% had guidance on changing the surgical technique (such as switching from endoscopic surgery to open surgery). By the art. 8th, CFM Resolution No. 1,614/2001, Art. 52, Chapter XI, Code of Medical Ethics, Art. 94, Chapter XI, Code of Medical Ethics, Art. 97, Chapter XI, Code of Medical Ethics and Art. 6th CFM Resolution No. 2,318/2022,³²-³⁴ summarily suggests that the auditor cannot authorize, object, or modify procedures requested by the assisting physician. For the percentages found, these may be the most common impositions, because when the healthcare provider, represented by their doctor, completely denies the surgical procedure, they do exactly that: vet a medical request. Or, if you still suggest another technique or change the codes and materials requested, the medical auditor will modify accordingly. This indicates that the professional freedom and autonomy of the assistant physician are being reduced.

In 3,63% of audits, there was an attempt to impose material marks on the assisting physician, modifying their choice. This information goes against Art. 12, CFM Resolution no. 1,614/2001,³³ where it says that the auditor may not mediate agreements between service providers/operators that limit the professional exercise. By imposing material different from the requested, based on the lowest cost only, there is a limitation on the freedom of the assisting physician, impeding the execution of his work. Furthermore, the auditor may be extrapolating his attributions, as per Article 98o, Chapter XI, Code of Medical Ethics,³² therefore, when indicating other material is to intermediate negotiations.

The analysis of the medical audits revealed that a single company, referred to as Company 3, is responsible for 74.54% of the audit evaluations, followed by the operators’ audit at 3.63%, and subsequently by another company, referred to as Company 2, at 21.81%. This indicates a predominance in the audit market of a few companies, in addition to the company that conducted audits most often (76.36%), which does not have registration in the Regional Council of Medicine where the audit was conducted. This was the case with the auditors and board doctors, where 67.27% did not have registration in the Regional Council where the audit was carried out. According to Article 1 of CFM Resolution 1,614/2001,³³ auditors or their audit firms must be registered in the CRM of the jurisdiction where the audit was performed. According to the results, this is a very common situation, where a doctor or company in the role of an auditor of another state practices its medical act in the state where the audit was requested, but without local registration, which can lead to harm to the auditors and the medical board in front of their councils. Despite this, the ANS Normative Resolution 424 of 2017 authorizes the conduct of a remote medical board, despite the function of the organ not to regulate medical activity.

We know that requests for procedures denied by the plan must come with the name and CRM of the auditor as already indicated by Art.4o, CFM Resolution of 1,956/2010, repealed and replaced by Art. 6th CFM Resolution No. 2,318/2022, however,³⁴ of the cases analyzed 10.90% came without identification of the doctor auditor.

The technical advice of the audits and medical committees plays a decisive role in defining the coverage of the procedure or treatment by the health plan. If the audit and medical board considers that the procedure is necessary and appropriate, the health plan operator shall bear the costs. Although it plays an important role in evaluating medical procedures and treatments, the medical junta has some limitations. Otherwise, the patient may appeal to ANS and subsequently seek coverage for the procedure judicially. This resource has continued to grow in Brazil.²¹,³⁵,³⁶

Audits and medical committees should ensure impartiality and decision-making based on technical and scientific criteria. But some criticism is being made about the impartiality of the medical board. There are cases where the third parties chosen to compose the board have ties to the healthcare plan operators, which can raise questions about the impartiality of the decisions made. In addition, it can trigger a series of dissatisfaction among patients, thus increasing the incidence of judicialization.

The increase in judicialization can lead to great economic losses for healthcare operators. Due to the high percentage of outsourced companies in the sector, healthcare operators often respond judicially to analyses carried out by these companies. Therefore, the managers of healthcare operators should pay attention to the quality of the audit and medical boards carried out by the companies that hire, as failures in the provision of services can lead to significant economic losses, especially when dealing with high-cost procedures such as spinal surgery.

CONCLUSION

Despite the limitations and criticisms that may arise, medical audits and boards are important tools to ensure that patients receive the appropriate and necessary treatment. They contribute to the efficiency and quality of the healthcare system, avoiding abuses and ensuring access to medical care. It is essential that the medical boards are composed of qualified and impartial professionals in order to ensure fair decision-making based on technical and scientific criteria. In this way, we can ensure the health and well-being of patients, promoting a more efficient and fair healthcare system. However, it is necessary that responsible bodies create mechanisms so that the audits and medical boards fulfill their role fairly for all, especially for the patients who may be the most affected. On the other hand, healthcare operators should also be attentive to the quality of the audits and medical board so that there are no failures that can lead to unnecessary judicialization or economic losses.

• Study conducted by the Adry Health Care, Rua Domingos de Morais, 2781, Vila Mariana, São Paulo, SP, Brazil. 04035-001.
• Reviewed by:
  Alexandre Fogaça Cristante

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Publication Dates

• Publication in this collection
  08 Aug 2025
• Date of issue
  2025

History

• Received
  16 Mar 2025
• Accepted
  05 June 2025