Applied Tax Planning to Medical Activities

Eduardo Halley Gois Santos; Raphael José Pereira Freitas

DOI: 10.22167/2675-6528-202602849

Article derived from a Course Conclusion Work (TCC), with content based on the student’s original work and adapted to the editorial format of the E&S Magazine with the support of the ResumeAI tool, an artificial intelligence solution developed by Instituto Pecege for textual synthesis and organization.

Summary

This study compared the taxation of medical activities carried out by individuals and by legal entities subject to Simples Nacional, Presumed Profit, or organized as a single-professional simple partnership. The objective was to compare the monthly amount of taxes and payroll charges under different combinations of practice type, corporate structure, and applicable tax system for medical activities. To this end, numerical simulations were performed with hypothetical data, considering CNAE 8630-5/03 for outpatient medical activity restricted to consultations, with monthly billings from R$10,000.00 to R$400,000.00. The Simples Nacional (Annexes III and V), Presumed Profit (with and without hospital equalization), simple partnership (fixed ISSQN), and autonomous individual were analyzed, including parameterized payroll charges such as Employer Social Security Contribution, RAT, third-party contributions, and FGTS. The results showed that the inclusion of these charges altered the ranking of the alternatives. Simples Nacional with Factor R showed an advantage in the initial and intermediate ranges, while Presumed Profit with hospital equalization was competitive at higher billings. Certain legal entity configurations presented a lower amount of taxes and charges than individuals. It was concluded that medical tax planning requires compatibility between billing, personnel, corporate structure, and legal requirements, with the results being illustrative and not representing the total operational cost.

Keywords: Medical activity; Hospital equivalence; Presumed Profit; Tax planning; Simples Nacional.

1. Introduction

The Brazilian tax system is characterized by a high tax burden and complexity. According to the Brazilian Institute of Planning and Taxation (IBPT, 2023), Brazil ranks among the countries with the highest tax burdens in the world, with tax collection corresponding to 33.4% of the Gross Domestic Product in 2023. More importantly, since 2011, the country has remained in last place in the Index of Return of Social Welfare, an indicator that measures the return of tax collection in benefits to the population. This scenario highlights not only the high level of taxation but also the inefficiency in the management and application of public resources. The complexity and excessive bureaucracy of the system require companies to adopt tax planning as a management tool (Silva and Faria, 2017).

Tax planning consists of the study of lawful alternatives to anticipate, reduce, or avoid the incidence of taxes, always within legal limits. In the doctrinal sphere, Mazza (2023) and the majority view equate tax planning with tax avoidance. However, authors like Greco (2008), cited by Almeida (2020), propose a distinction: in planning, the analysis falls on the taxpayer’s conduct, considering contractual freedom and the lawfulness of actions, while in avoidance, the focus is on the effects of this conduct regarding the incidence and collection of the tax. Regardless of these subtle divergences, the understanding prevails that both constitute lawful tax economy conduct, provided that legal limits are observed.

It is fundamental not to confuse these practices with tax evasion or avoidance, which are characterized by illegality and the intention to conceal or disguise the tax-generating event. Andrade (2014) defines evasion as the realization of the taxable event concealed from the tax authorities, meaning the negligent non-fulfillment of the tax claim. Almeida (2020), citing Huck (1998), reinforces that evasion consists of the deliberate use of illicit means to evade the payment of the due tax. Avoidance, on the other hand, a distinct figure from both, constitutes a simulated legal act, intended to improperly disguise, reduce, or suppress the due tax (Mazza, 2023).

In the context of medical activities, this scenario becomes especially relevant due to the size of the professional category and the predominant form of insertion in the labor market. Scheffer (2025) estimates that Brazil will reach a total of 635,706 active physicians, which corresponds to a ratio of 2.98 professionals per thousand inhabitants. In the last five years alone, the country has gained 116,546 new physicians, highlighting the economic and social significance of this category.

For tax discussion, the labor linkage profile of these professionals is crucial. Data from the Annual Social Information Relation, processed by Scheffer (2025), indicate that in December 2023, only 190,917 doctors had a formal employment link, corresponding to 33.3% of the 572,960 active doctors in the country. This percentage has been continuously decreasing, outlining a clear trend of predominance of informal hiring modalities. This means that about two-thirds of Brazilian doctors work outside the CLT or statutory regime, providing services predominantly through Legal Entity, cooperatives, and other autonomous modalities, a phenomenon known as pejotization.

The diversity of professional practice forms makes it relevant to compare the taxes and charges levied on each alternative. The differences between the regimes can alter the amounts directly disbursed by the professional or by the Legal Entity, especially when considering revenue, payroll, pró-labore, social security contributions, the Severance Indemnity Fund (FGTS), and specific tax treatments. However, the data do not allow us to conclude that taxation is the exclusive or determining cause of “pejotização” (the practice of hiring individuals as legal entities), a phenomenon involving legal, labor, social security, contractual, and organizational factors. Given this context, this study seeks to identify which combination of activity practice form, corporate structure, and tax system results in the lowest amount of taxes and charges directly modeled for medical activities, considering different monthly revenue ranges and legally conditioned tax benefits.

The objective of this study is to compare the monthly amount of directly calculated taxes and payroll charges included in the premises under different combinations of exercise form, corporate form, and tax system applicable to medical activities.

2. Material and Methods

This study adopted a quantitative-descriptive approach, based on the comparative analysis of the taxation applicable to medical activities in the main tax systems in force in Brazil. The research was developed through numerical simulations, with the objective of comparing the monthly amount of taxes and charges in different combinations of practice type, corporate structure, and tax system, according to the established objective.

The information used for the construction of the scenarios was obtained from primary sources from the Brazilian Federal Revenue Service (RFB), current tax legislation, including Complementary Law No. 123/2006, Law No. 9.249/1995, Law No. 9.718/1998, and Law No. 11.727/2008. The sources were complemented by RFB Normative Instructions No. 1.700/2017, No. 2.110/2022, CGSN Resolution No. 140/2018, and RDC ANVISA Resolution No. 50/2002, in addition to specialized doctrinal and technical works by Mazza (2023), Almeida (2020), and Silva and Faria (2017).

The research was developed in four sequential stages. In the first stage, a bibliographic and documentary survey of the tax legislation applicable to medical activities was carried out, covering federal, municipal, and social security regulations. In the second stage, the formulas for calculating the taxes pertinent to each tax system were systematized.

In the third stage, an electronic spreadsheet was built for performing the numerical simulations, with parameterization by billing points. In the fourth stage, the results were tabulated and compared, allowing observation of the ordering changes between regimes at the simulated points, without presenting empirical findings or interpretations.

The tax simulations were built for monthly billings ranging from R$10,000.00 to R$400,000.00, with progressive intervals. The CNAE code 8630-5/03 was adopted as the exemplary economic activity, corresponding to outpatient medical activity restricted to consultations, for exclusively parametric purposes.

Seven distinct frameworks were evaluated. These included: (a) Legal entity (PJ) opting for Simples Nacional, with activity subject to Factor R and taxation under Annex III; (b) Business partnership subject to Presumptive Profit, with full hospital equalization for IRPJ and CSLL purposes, with a proportional ISSQN of 3%.

Also evaluated were: (c) Business company subject to Presumed Profit, with 50% of revenue qualifying for hospital equalization conditions and 50% subject to ordinary percentages, with proportional ISSQN of 3%; (d) Single professional partnership, with federal taxation under Presumed Profit and fixed municipal ISSQN calculated per qualified professional.

Scenarios completed: (e) Business company subject to Presumptive Profit, without hospital equalization and with proportional ISSQN of 3%; (f) Legal entity opting for Simples Nacional, without adopting the R Factor (reason r < 0.28), subject to taxation under Annex V; and (g) Self-employed individual, with incidence of Personal Income Tax and fixed ISSQN in the base scenario, without inclusion of the individual contributor’s INSS.

To ensure the comparability of the scenarios, it was assumed that the monthly total sales remained constant during the twelve months prior to the reporting period. Thus, for each monthly gross revenue value (R), the accumulated gross revenue in the previous twelve months (RBT12) was calculated by RBT12 = 12 × R. The simulation represented a company already in operation for at least twelve months.

It was considered that all revenue derived from the provision of medical services subject to the same tax treatment, with no export revenue, financial revenue, revenue from distinct activities, or deductions from canceled sales and unconditional discounts. The accrual basis was adopted for revenue recognition purposes. The calculation bases and rates adopted corresponded to the rules established by federal, municipal, and social security legislation, considering the parametric values used for the calendar year 2026.

In the Simples Nacional with R Factor, a gross payroll of employees corresponding to 28% of the monthly gross revenue was assumed, a premise sufficient to ensure compliance with the minimum ratio of 28% between payroll and the accumulated gross revenue of the previous twelve months. The FGTS, due to its distinct nature from the Simples Nacional Collection Document (DAS), was added separately in the tables with charges.

The simulation for individuals considered a single self-employed doctor, with no dependents, alimony, or other legal deductions, without deductible expenses recorded in the Cash Book, and using the monthly simplified discount of R$607.20. The IRPF was calculated using the progressive monthly table of 2026 from the RFB (2025), and the fixed municipal ISSQN for self-employed professionals in the Municipality of Belo Horizonte was converted from a quarterly to a monthly value.

For the simple uniprofessional company, a single qualified professional providing services on behalf of the company was considered, with a pro-labore equivalent to 28% of the gross monthly revenue. On this pro-labore, the Employer’s Social Security Contribution (CPP) of 20% was included. Occupational Environmental Risk (RAT), contributions to third parties, or FGTS were not included, as the scenario did not presuppose the existence of employees.

For the Presumed Profit, a 3% ISSQN rate was adopted on gross revenue as a uniform parametric hypothesis. In the scenarios submitted to Presumed Profit, a gross employee payroll corresponding to 28% of the monthly gross revenue was assumed. On this payroll, CPP of 20%, RAT of 1%, contributions to third parties of 5.8%, and FGTS of 8% were calculated.

For contributions intended for third parties, the Social Security and Social Assistance Fund (FPAS) 515 was adopted, applicable to healthcare service establishments and professional practice offices constituted as legal entities, with a global rate of 5.8%. The Accident Prevention Factor (FAP) was considered neutral, equal to 1.000. In the Simples Nacional, the employer’s CPP, the RAT, and third-party contributions remained incorporated into the DAS, with FGTS being included separately.

The individual social security contribution on “pró-labore” was not included in the totals for legal entities, as it is a value withheld from the insured and not an employer’s charge. The “Actual profit” was excluded from the numerical simulations due to its high variability and the impossibility of comparative parameterization with the other regimes, which operate on predefined calculation bases.

3. Results and Discussion

The comparative tax simulation, developed according to the proposed methodology, revealed the behavior of the tax burden on medical activities under different tax systems and legal organizational forms. The analyses were conducted for monthly billings ranging from R$10,000.00 to R$400,000.00, allowing for the identification of the most advantageous combinations across distinct revenue ranges. The study was divided into two main stages: the first evaluated taxes directly calculated without the inclusion of additional payroll charges, and the second re-evaluated the scenarios with the incorporation of these charges, offering a more comprehensive perspective of the total burden.

In the initial stage, when considering only taxes directly levied on revenue, the Simples Nacional with R Factor (Annex III) proved to be the most advantageous alternative in initial and intermediate revenue ranges. In contrast, the Business Company with hospital equalization presented itself as the most competitive option at higher revenues, while the self-employed Individual consistently registered the highest amount of taxes. The Uniprofessional Simple Company with a fixed ISSQN also proved to be a relevant alternative, especially at lower revenues, highlighting the importance of the corporate structure in defining the tax burden.

The detailed analysis of the results without charges revealed that, for billings up to R$30,000.00, Simples Nacional with Factor R was the most beneficial regime, followed by the Society with hospital equalization. For billings between R$40,000.00 and R$60,000.00, the Society with hospital equalization took the lead, with Simples Nacional with Factor R in second place. This trend consolidated for billings from R$90,000.00 to R$400,000.00, where the Society with hospital equalization maintained the position of the most advantageous regime, followed by the Society with 50% hospital equalization. Individual Persons, in turn, remained with the highest tax burden in all analyzed ranges.

The inclusion of additional payroll charges substantially altered the ranking of tax alternatives, providing a more realistic view of the total cost. In the Presumed Profit scenarios, the Employer’s Social Security Contribution (CPP), the Environmental Workplace Risk (RAT), contributions to third parties, and the Severance Pay Fund (FGTS) were added. In Simples Nacional, only FGTS was added separately, while in the uniprofessional simple partnership, CPP on pró-labore was included. This reassessment demonstrated that the nominal advantage of some regimes was partially reduced due to the impact of these charges.

In the scenarios modeled with the inclusion of charges, it was observed that external charges corresponded to 9.744% of the monthly revenue of companies subject to Presumed Profit. In contrast, for Simples Nacional with Factor R, these charges represented 2.24% of revenue. This difference in the tax incidence of charges had a direct impact on the competitiveness of the regimes, modifying the ranking observed in the first stage of the simulation. The analysis showed that a simple comparison of nominal rates or direct taxes can lead to an incomplete ranking and, potentially, to misguided planning decisions.

In the monthly billing of R$100,000.00, Simples Nacional with Factor R presented the lowest amount of taxes and charges, totaling R$15,270.00. Next, the single-professional simple partnership registered R$18,409.00, and Presumed Profit with hospital equalization reached R$18,674.00. Presumed Profit without equalization, in turn, summed R$25,274.00, while the self-employed individual presented R$26,535.00. These data show that, even with the inclusion of charges, certain legal entity configurations maintained a significant advantage over the taxation of individuals.

At higher billing levels, the dynamics of the tax systems changed. At the point of R$250,000.00 per month, Presumed Profit with hospital equalization became the most advantageous alternative, with R$46,685.00, slightly lower than Simples Nacional with Factor R, which totaled R$47,630.00. For a billing of R$400,000.00, Presumed Profit with hospital equalization registered R$75,896.00, while the individual reached R$109,035.00. This difference of R$33,139.00 per month represented a saving of 30.39% of the simulated tax burden for the individual, reinforcing the hypothesis that the establishment of a legal entity can be more efficient in certain contexts.

The Simples Nacional with R Factor demonstrated relevance in the initial and intermediate revenue ranges, but its advantage does not stem solely from the nominal rate of the regime. The maintenance of the benefit is conditioned on the existence of an effective and regularly declared payroll, at a sufficient percentage for classification in Annex III. The remuneration required to meet the R Factor represents an economic cost for the company, and the reduction of the Simples Nacional Collection Document (DAS) cannot be analyzed in isolation from the labor, social security, and operational charges associated with the payroll.

Hospital equalization also proved to be an important tool for tax planning. However, its effects should be evaluated after the inclusion of employer charges. In the scenario of R$100,000.00 per month, the tax burden of Presumed Profit with full equalization fell from R$25,274.00 (without benefit) to R$18,674.00. This reduction of R$6,600.00, equivalent to 26.11% of the burden in the scenario without equalization, showed that, although payroll charges reduce the relative savings of the benefit, equalization still provides a considerable fiscal advantage.

The simple single-professional company showed competitive performance across various revenue ranges, but should not be automatically considered the most advantageous alternative. The inclusion of the Employer’s Social Security Contribution on the pro-labore, calculated at 28% of gross revenue, reduced the advantage derived from the fixed Municipal Service Tax. The position of this type of company in the final ranking may change if the company has no employees or adopts a different pro-labore percentage than the one used in the simulation, or if there are employees, whose charges must be added.

The results confirmed that the autonomous individual presented a higher tax burden than the best alternative of a legal person/ entity in all billing points analyzed. This finding supports the hypothesis that certain legal person/ entity configurations may be more efficient than operating as an individual. However, the simulations do not allow us to conclude that taxation is the exclusive or determining cause of “pejotização” (incorporation), a multifaceted phenomenon that involves legal, labor, social security, contractual, and organizational factors, in addition to fiscal aspects.

The legal form adopted by the doctor or clinic has a relevant influence on the amount of taxes and charges directly modeled. Tax savings depend on the material adherence between the legal structure, operational organization, and the legal requirements of each benefit. The constitution of a simple partnership, a limited liability company, or acting as an individual are not merely formal choices, but strategic decisions that impact tax incidence, access to tax benefits, and the level of exposure to tax enforcement risks.

The improper use of business entities without effective business organization, or the maintenance of a business structure in the form of a simple partnership solely for the purpose of enjoying the fixed ISSQN, may constitute simulation. In such cases, the tax authority is authorized to disregard the legal acts or transactions, reclassifying the taxation according to the underlying economic reality, which may result in retroactive tax assessments, fines that can reach 150% of the amount due in case of willful misconduct, and interest.

The application of Factor R in Simples Nacional and the classification as a society equivalent to a hospital require material adherence to legal requirements. For Factor R, an effective payroll of at least 28% of gross revenue is necessary. For hospital equivalence, it is essential to have infrastructure compatible with the Collegiate Board Resolution (RDC) ANVISA nº 50/2002. Non-compliance with these requirements can lead to the denial of benefits, retroactive tax assessment, and the application of penalties.

In this context, social security oversight and the restrictive interpretation by the Brazilian Federal Revenue Service (RFB) regarding labor leasing and the nature of medical services, as consolidated in Normative Instruction RFB No. 2.110/2022 and in COSIT Consultation Rulings, are crucial aspects. Such positions impact clinics that provide services to hospitals and health plan operators, as the contractual dynamic can be framed as placing professionals at the disposal of third parties, with repercussions on the classification within the Simples Nacional and on the applicable social security withholdings.

Tax planning in the healthcare sector should be conceived as a continuous, integrated, and documentarily supported process, not as a one-off operation to reduce tax rates. The most advantageous tax systems identified in this study only remain beneficial as long as the corporate structure, accounting records, and the actual operation of the clinic verifiably reflect the legal assumptions that underpin them. In summary, legitimate tax savings result from material compliance with the legal requirements of each tax system, ensuring legal certainty and avoiding tax risks.

In summary, the results of this study demonstrated that there is no universally more advantageous tax system for medical activities, with the ideal choice depending on the interaction between billing, legal structure, personnel structure, pro-labore, calculation regime, municipal treatment of ISSQN, and legal requirements for tax benefits. The inclusion of payroll charges significantly altered the ranking, with Simples Nacional with Factor R showing an advantage in initial and intermediate brackets, and Presumed Profit with hospital equalization standing out in higher billings. The legal entity, in specific configurations, proved more efficient than the individual, but this advantage is conditioned on material adherence to legal requirements, not justifying the creation of fictitious structures or the undue use of tax benefits.

4. Conclusion

The study aimed to compare the monthly amount of directly calculated taxes and payroll charges across different combinations of business structure, corporate form, and tax system applicable to medical activities. It was found that the inclusion of payroll charges significantly altered the ranking of tax alternatives. It was observed that Simples Nacional with Fator R presented the lowest amount of taxes and charges in initial and intermediate revenue ranges. At higher revenues, Presumptive Profit with hospital equalization became the most advantageous alternative, surpassing Simples Nacional with Fator R and the self-employed individual. It was identified that certain legal entity configurations resulted in a lower amount of taxes and charges than that of individuals across all analyzed revenue points, such as in the scenario of R$100,000.00 monthly, where the best legal entity presented R$15,270.00 versus R$26,535.00 for the individual, and at R$400,000.00, with R$75,896.00 for the legal entity and R$109,035.00 for the individual. The study’s main contribution lies in demonstrating that medical tax planning is not limited to choosing a tax system, but requires the harmonization of revenue, personnel structure, corporate form, and legal requirements for the enjoyment of tax benefits, offering a comparative framework for strategic decisions.

However, the results are illustrative and do not represent the company’s total operating cost, profitability, or competitiveness, being dependent on the assumptions adopted. The analysis does not allow concluding that taxation is the exclusive cause of “pejotização” (hiring of legal entities instead of individuals), a multifaceted phenomenon. The advantage of tax systems like Simples Nacional with Factor R and hospital equalization is conditioned on material adherence to legal requirements, such as the existence of an effective payroll or compatible infrastructure, under penalty of denial of benefits and tax assessments. It is suggested that tax planning in the healthcare sector be a continuous, integrated, and documentarily supported process, avoiding the creation of fictitious structures or the undue use of tax benefits. Future studies may deepen the analysis of the interaction between total operating costs and the tax burden, as well as investigate the impacts of legislative changes and contractual dynamics on the provision of medical services.

Bibliographic References

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Greco, M. A. 2008. Planejamento tributário. 2. ed. Dialética, p. 81-82. In: Almeida, T. S. Planejamento tributário: constituição de EIRELI para serviços médicos. Almedina Brasil.

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Mazza, A. 2023. Manual de direito tributário. 9. ed. Saraiva Jur. Disponível em: https://app.minhabiblioteca.com.br/reader/books/9786553627284/. Acesso em: 28 out. 2025.

RFB – Receita Federal do Brasil. 2022. Instrução Normativa da Receita Federal do Brasil nº 2.104, de 20 de jun. Dispõe sobre a Escrituração Contábil Fiscal (ECF). Diário Oficial da União, Brasília.

RFB – Receita Federal do Brasil. 2025. Tributação de 2026. 12 set. 2025. Disponível em: https://www.gov.br/receitafederal/pt-br/assuntos/meu-imposto-de-renda/tabelas/2026. Acesso em: 27 jan. 2026.

Scheffer, M. 2025. Demografia Médica no Brasil 2025. Brasília, DF: Ministério da Saúde; Faculdade de Medicina da Universidade de São Paulo; Associação Médica Brasileira. Disponível em: http://bvsms.saude.gov.br/bvs/publicacoes/demografia_medica_brasil_2025.pdf. Acesso em: 23 abr. 2026.

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Article originating from the Course Conclusion Work of the Specialization in Tax Management of the MBA USP/Esalq

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