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The aim of this research is to analyze the procedures used in environmental cost management in hospitals in the northwestern region of Rio Grande do Sul (RS). As for the methodological procedures, this study is characterized as: (I) applied research; (II) qualitative; (III) descriptive; supported by the multiple case study methodology. Bibliographies and national and international publications, interviews, documentary analysis and on-site observations were used. The sample consisted of four hospitals. The results showed that hospitals take action to protect and preserve the environment, but that information about these actions is not yet widespread and there is no specific management of the costs of their environmental actions. Given that many costs related to environmental issues are accounted for together with the other costs processed by the entities, it can be concluded that these entities are not prepared for cost management of an environmental nature.