How to negotiate with the payer's auditor: technique, documents and minutes

What does negotiating with the payer's auditor mean?

It is the clinical discussion between the hospital's auditors and the health plan's (operadora's) auditors about items that were denied, or are about to be, based on the medical record, the contract and the rules. It can happen before the claim is closed (during concurrent review, while the patient is still admitted) or after the denial, as part of the appeal.

Negotiation does not replace the appeal: what is agreed only becomes money if it is formalized through the channel set in the contract and in TISS (Troca de Informações na Saúde Suplementar), the national standard for electronic data exchange between providers and health plans. The pillar guide Medical claims auditing explains the types of audit and who performs each; Hospital claim denials shows where denials come from.

This guide covers clinical (technical) denials, which challenge the medical necessity of a procedure, supply, drug, daily rate or length of stay. Administrative denials (invalid member ID, expired authorization, coding error) are usually fixed by correcting and resubmitting, with no meeting.

The room to negotiate shows in the numbers

The gap between what the health plan denies at first and what the hospital ends up accepting is where negotiation works. At hospitals that belong to Anahp (Associação Nacional de Hospitais Privados, the national association of private hospitals), the initial denial rate was 15.93% of amounts receivable from health plans in 2025 ^[7]. Anahp's quarterly report describes this indicator as denied amounts still under negotiation ^[7].

Accepted denials, the final loss, were 1.72% of gross revenue from health plans in the same year ^[7]. The denominators differ, so the two figures should not be subtracted from each other. Still, they show that much of what is denied gets discussed again.

Anahp also notes that, beyond accepted denials, hospitals accept discounts in settlements to get invoices paid ^[7]. That amount does not show up in the denial indicator, so a poorly recorded negotiation can hide a loss.

What do the rules guarantee the hospital in a negotiation?

The basis of the negotiation is the contract, and RN 503/2022 (Resolução Normativa, a binding rule) from the ANS (Agência Nacional de Saúde Suplementar, Brazil's private health plan regulator) defines what it must contain. Article 14 requires the contract to set out the administrative and clinical audit routine, the grounds for denial, the appeal deadline, the health plan's response deadline and the payment deadline when a denial is reversed. Its sole paragraph requires the appeal deadline to equal the response deadline ^[1].

Article 5 bars the health plan from blocking the provider's access to audit routines and denial justifications (item V) and from blocking appeals (item VI). Both rules apply when billing follows the current TISS version (sole paragraph) ^[1]. Law 9,656/1998 (art. 17-A, added by Law 13,003/2014) already requires a written contract with billing and payment deadlines and procedures ^[8].

On the ethics side, the auditor's rules apply:

How these rules apply to a specific case is for the hospital's legal team; at the table, they support a request for written justification. The guide Physician audit details the suspended articles and those still unmarked.

How do you prepare for the meeting with the auditor?

Whoever arrives with the claim triaged, the reason for each denial and the evidence sorted discusses items, not impressions. A practical sequence:

1. Read the remittance report. Identify each denied item, its amount and the reason code from table 38 of TUSS (Terminologia Unificada da Saúde Suplementar, the national code set) ^[6]. The guide Claim review and payment statements shows how to read the file.
2. Triage internally. Sort each item into three groups: valid denial (accept it and fix the cause), invalid denial with proof, and debatable denial (depends on clinical or contractual interpretation). The meeting focuses on the third group.
3. Add up the amounts by group. Start with the largest recoverable total, not with the order of the claim.
4. Check the deadline. The contract sets the appeal deadline ^[1]. The meeting does not stop that clock unless the contract or a written agreement says so. See Denial appeal deadlines.
5. Decide who speaks. Denials about medical decisions are discussed by a physician auditor; denials about nursing records and items, by a nurse auditor. Law 12,842/2013 reserves physician audit to physicians (art. 5, II), and Cofen 720/2023 reserves audit within the nursing team to nurses ^[10][4].
6. Ask for the agenda in writing. Send the list of claims and items in advance and ask the payer's auditor for the justification of each denial, based on RN 503/2022, art. 5, V ^[1].

Argument and evidence for each type of clinical denial

Each argument needs a document to support it. The table sums up common pairings in appeal practice:

One caution: the contractual argument comes before the clinical one when the contract already settles the matter. Debating the medical necessity of an item the contract annex says must be paid opens an unnecessary discussion.

In the meeting, what changes the outcome?

Conduct in the meeting tends to weigh less than preparation, but three practices make a difference. First, discuss item by item, with the document on screen, and record each decision before moving on. Second, separate the clinical from the commercial: a discount or settlement amount is a decision for someone with authority, not for the auditor.

Third, keep the conversation between peers and in writing. The Medical Code of Ethics bars the auditor from commenting in front of the patient and from interfering in the attending physician's acts, and requires observations to go into the report (art. 94) ^[3]. When the auditor questions a treatment decision, the route is a written question to the attending physician, who must answer promptly (CFM 2,448/2025, arts. 10, I, and 14) ^[2].

How do you record what was agreed?

An agreement only exists if it is written and signed. At the end of each meeting, the minutes should include:

• date, place or channel, participants with title and professional license (CRM or Coren);
• claims discussed, with batch, claim form and receipt numbers;
• for each item: denied amount, decision (reversed, upheld, partly reversed, pending), agreed amount and rationale;
• open items with an owner and a deadline;
• how the reversed amount will be paid (denial appeal, new billing or another route in the contract) and the agreed deadline;
• signatures of the auditors on both sides.

Then the agreement goes back into the TISS workflow. The standard's Organizational Component provides four messages for denial appeals: the appeal, the receipt, the status request and the response (item 51) ^[5]. The receipt proves the health plan got the appeal (item 55) ^[5]. In the response, table 38 has codes such as 3095 (denial appeal accepted); code 2904 flags more than one appeal for the same claim form ^[6]. Sending the appeal with the minutes attached and checking the response code closes the loop. The Denial appeals guide walks through each step.

What if there is no agreement?

Without agreement, the item is recorded as upheld or pending in the minutes, and the hospital decides whether to accept the denial or escalate. The usual routes are a formal appeal within the deadline, a discussion with the health plan's commercial or provider relations team, the technical committee set in the contract, if there is one, and, as a last resort, litigation assessed by the legal team.

ANS Public Consultation 170/2026 (Consulta Pública), which proposes merging RNs 503 and 512, included mediation and conciliation mechanisms and payment of the undisputed amount in its draft ^[11]. As of October 17, 2026, the final rule had not been published ^[11]. Until a new rule is published, RN 503/2022 and the contract remain the reference.

When the health plan obstructs appeals or denies access to justifications, the hospital can report it to the ANS through its channel for irregular practices between health plans and providers ^[9].

What we see in operations

At Accrua, a meeting with the health plan's auditor starts well before the agenda. For each item under discussion, Accrua OS gathers the denial reason, the relevant part of the medical record, the contract clause, the current price table and the history of that reason with that health plan. The person negotiating is an auditor from our team with nursing training, who comes to the meeting with the evidence organized item by item.

What is agreed in the meeting has to go back through the formal process to turn into payment. That is why each agreement is logged with item, amount and basis, and agents follow the TISS appeal, the receipt and the payment through to remittance reconciliation.

Accepting a denial or conceding an item is always a person's decision, logged with who made it, on what basis and when. The argument that worked, and the one that did not, goes back into the review of that health plan's next claims.

Where to start

1. Create a minutes template with the fields in the recording section and use it in every meeting, in person or remote.
2. Reread the audit clause of each contract and note the grounds for denial, appeal deadline, response deadline and how reversed denials are paid. See Hospital–payer contract.
3. Set up three-group triage (valid, invalid with proof, debatable) for each remittance report before scheduling a meeting.
4. Define approval limits: up to what amount the hospital's auditor can settle, and when the decision goes up to management.
5. Track the follow-up: check whether each item reversed in the minutes was paid, and with which response code.