Social Security suspends access of 167 experts on suspicion of irregular denials of sickness benefit

According to the ministry, the restriction began to be adopted in May this year, about a month after the so-called Qualified Atestmed came into operation. The reformulated version of the system was created to make the remote analysis of documents presented by policyholders more detailed and help reduce the queue at the INSS (National Social Security Institute).

The ministry states that Atestmed's general grant and rejection rates remain similar to those of in-person examinations, with around 60% to 65% of approvals and between 35% and 40% of denials.

Even so, he says he identified, between April and May, cases with rejection percentages well above the average, which led to a deeper analysis of the experts' decisions.

Evidence was also found of repeated use of standardized justifications, without sufficient individualization of the documents presented in each process, which led to the restriction. In one of the cases analyzed, for example, an expert rejected more than 90% of the requests evaluated, with analyzes lasting less than five minutes.

The benefit requests analyzed by the affected experts are undergoing review, according to people familiar with the matter interviewed by the report. The cases are being reevaluated by other experts and, when these professionals identify that the insured was entitled to the benefit, the grant is made.

ASSOCIATION DISPUTES RESTRICTION

The ANMP (National Association of Federal Medical Experts) contests the measure and has taken legal action against the ministry. In a statement, the entity's president, Luiz Carlos de Teive e Argolo, states that the association does not question the statistical data presented by the government, but the way in which they were used.

"There is no minimum or maximum concession percentage in the legislation, nor a target for approval or rejection", he states.

According to Argolo, law no. 11,907/2009 guarantees technical autonomy to experts. "A higher rejection rate reflects the legitimate technical rigor of each professional, and not an irregularity. Diverging from the average does not constitute any infraction."

In a note, the ministry states that the decision is precautionary and temporary in nature and results from the monitoring of analyzes carried out by the DPMF (Department of Federal Medical Expertise).

According to the ministry, the analysis considered aspects such as the documentation presented, the justifications recorded by the experts and the time taken to complete the tasks. It also evaluated the relationship between the medical documents and the conclusion adopted.

The ministry also states that the measure seeks to guarantee technical, impartial and individualized decisions and reported that it is preparing national training within the next 15 days for all experts on the operation of the new Atestmed.

Despite the restriction on the system, the ministry states that professionals continue to be able to carry out in-person examinations and other career activities.

NEW ATESTMED

The restriction comes just months after the government reformulated Atestmed. The changes, implemented following recommendations from the TCU (Federal Audit Court), now allow experts to deny requests made exclusively based on documentary analysis – a possibility that did not exist in the previous model.

Paulo Liporaci, ANMP lawyer, states that the experts had access to the system restricted without prior communication and without the establishment of an administrative procedure that would allow them to present a defense before the measure.

According to him, the implementation of Qualified Atestmed occurs at a time when the Lula (PT) government seeks to consolidate the reduction of the INSS queue, an issue that gains greater relevance in an election year.

For the entity, however, in-person expertise continues to be the most appropriate model for evaluating the granting of benefits due to temporary incapacity.

DIVERGENCE ABOUT THE CRITERIA

Liporaci also states that the high rejection rates may have different explanations. Among them, he cites the adaptation phase to the new system and a more rigorous stance on the part of experts, who understand that certain cases require in-person evaluation.

It also mentions the distribution of processes among professionals, as some may receive proportionally more requests with insufficient documentation or inconsistencies, which would result in a greater number of denials.

The lawyer also disputes the association made by the ministry between analysis time and the quality of the decision. According to him, there are situations in which rejection can occur within a few minutes.

This happens, for example, when the insured fails to present a medical certificate and attaches manifestly inappropriate documents, such as a selfie or a photograph of a part of the body. In these cases, he states, the denial may be immediate due to the lack of required documentation.

The association also disputes the ministry's conclusion that standardized reasons were used. According to Luiz Carlos de Teive and Argolo, analyzes gathered by the entity show that the opinions contained individualized information, such as ICD, CRM of the responsible doctor and specific inconsistencies found in the documentation presented by the insured.

Documents gathered by the association also indicate that the time it takes for experts to analyze cases varies depending on the complexity, with some cases lasting between 5 and 31 minutes.

For ANMP, the government selected professionals solely based on statistics, without individually verifying whether the decisions were correct.

The entity also states that the restriction prevents experts from carrying out part of their duties for an indefinite period and may affect activities remunerated by productivity bonuses. The ministry denies it.

According to the ministry, the professionals were not removed from the management and productivity programs, and the restriction is limited to the analysis of requests by Atestmed Qualificado, and can be reversed after technical analysis, server manifestation and eventual training.

"The MPS reaffirms its commitment to legality, administrative efficiency, the technical autonomy of federal medical experts, the security of expert analyzes and the protection of insured people who depend on benefits of a food nature", adds the folder.

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