REGULATION AND CONTROL OF MEDICAL FEES IN ECUADOR
By Carlos Ramirez
Did you know that health is understood as the prolongation of life and not only as the absence of diseases? In order to meet this definition of health in Ecuador, a program called ACCESS was created. This entity is in charge of the regulation and control of charges for medical care in Ecuador. They do things such as issuing operating permits for private and public medical establishments and regulate the rates of medical procedures in Ecuador. Despite the existence of this entity there are some fees that can not be controlled or regulated by ACCESS itself or other entities.
The main mission of ACCESS is to monitor and control the quality of services provided by healthcare providers and companies that finance comprehensive prepaid health care services and insurance companies that offer healthcare insurance coverage. They ensure the safety of patients and users through regulation and quality assurance under the approaches of gender, culture, generational and bioethical rights. ACCESS stands for Agency for Quality Assurance of Health Services and Prepaid Medicine and is the institution in charge of exercising technical regulation, technical control and health surveillance in public, private and community health services, for profit or not-for-profit. This agency was created in 2015 by a presidential mandate and is included in the Ecuadorian constitution. This means that if you fall into a scam, malpractice, or are excessively charged you can exercise your right and summon to court the entity responsible.
One of the most common complaints we see are in regards to medical fees charged by doctors. These fees are variable depending on the doctor you choose and the same services may vary depending on your treating physician. This cannot be regulated by any entity in Ecuador since doctors exercise free professional practice and are not subject to charge the same price for medical care or hospital procedures. For this reason we always recommend that our members get at least two medical opinions and verify that the values to be charged are correct and that the procedure is adequate. For example, just a few months ago in December there was a case of a patient who was scammed by her doctor. She received a bill for $11,451.60 and after insurance she found out that they would only cover $839.95. This was obviously frustrating for our member especially because the service was just a minor procedure on her toe. The affiliate went to her doctor because she was suffering from pain and inflammation in her toe and the doctor decided to operate immediately. It was later revealed that this condition could be treated on an outpatient basis for the amount paid by the insurance company that reimburses the claim according to the rates accepted by the control entities in Ecuador. The client has now had to go to a new doctor since the procedure performed by this doctor was not necessary and only complicated her diagnosis.
She also incurred new medical expenses and is taking legal action.
If you go to a doctor and his first recommendation is to operate immediately, get out of there! Most of the time you will not require immediate care or you will be able to receive different care with the same results, for less. ACCESS cannot interfere in the value that a doctor will charge you for their medical fees, which is why at some doctors you will pay $30.00 for a medical consultation and at others up to $80.00. It is important to ask for a recommendation from friends and family about what doctors are best.
Medical fees can be complicated in Ecuador and can cause unnecessary burdens on both affiliates and advisors. Advisors should be able to communicate the appropriate value of services to their affiliates and be aware of the codes used for individual cases so that one is charged appropriately. There are some procedures and surgeries that can be preauthorized and you will only have to pay values not covered by your deductible and copayment. In this case you will not have to go through the subsequent process of reimbursement either. Remember that in Ecuador the submission of reimbursement documentation is the responsibility of the affiliate, not third parties, and if you have a broker their duty is to guide you through the process, help you understand the processes, send your documentation to the insurance company and communicate the status of your case, but it is not their job to collect and document your case, this obligation is the sole responsibility of the affiliate.
In general there is no law that regulates the medical fees of each doctor, but the law will always be in your favor if you are improperly charged for a medical service and would like to sue. You may also appeal to the insurance company by presenting a certificate that explains your medical services and the appropriate value for them. Although these are both options, the best thing to do would be to find a doctor who charges appropriately and gives you the care you deserve!