Optimalisatie van de werkingsprocessen van het Bijzonder ... - KCE

36 Special Solidarity Fund KCE Reports 133
Figure 3: All costs in the SSF sample as specified in the application in
function of the decision taken (black dot is the median, the red triangle is
the mean; the 10% most expensive applications are not shown).
5.2 PROCEDURE TO SUBMIT AN APPLICATION TO THE SSF
FOR REIMBURSEMENT
5.2.1 Submitting an application for reimbursement
Every citizen has the obligation to adhere to one of the 7 health insurance funds,
recognized by the Public health authority. Most of these health insurance funds are
structured on a regional basis and are divided in local “sickness funds”.
One of their tasks is to reimburse, under the supervision of the NIHDI, the costs of
medical treatments and drugs covered under the compulsory health system.
Whenever a citizen has medical expenses for which the compulsory health system
provides reimbursement, he has to enter the prescribed documents to his local sickness
fund. If the expenses meet the conditions set out by the public health system, the
sickness fund will reimburse the patient in accordance to the regulation and tariffs from
the NIHDI.
The same procedure is applicable for the requests for reimbursement of medical costs
that are covered by the SSF. The initiative to submit an application for reimbursement
of costs by the SSF has to be taken by the patient. The patient (or his representative) is
solely entitled to apply for reimbursement entering a demand to the local sickness fund
he adheres to. In order to be valid, the demand has to be introduced to the local
sickness fund at the latest 3 years after the medical intervention (art. 25septies §2 in
fine).
The local sickness funds mostly have social services that will help the patient (or his
representative) to compose his file in order to be eligible for reimbursement. These
local social services also inform and give advice to the patient on their rights and on
how to complete the request for reimbursement.
For the majority of the applications, a hospital physician can be identified as the
prescribing physician. In the SSF sample, for 69.1% of the applications, a hospital could
be identified. Most applications arise from a small number of hospitals: 74.8% of all
hospital related applications originate from 13 hospitals (7.9%), almost all linked to a
university. A similar phenomenon is found when looking at ICD-9-CM diagnostic class:
for most diagnostics classes, a limited amount of hospitals is responsible for the bulk of
applications (see figure 4).