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

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38 Special Solidarity Fund KCE Reports 133 Figure 5: Number of prescribers per percentage of applications they represent in the SSF sample in function of ICD-9-CM diagnostic class. 5.2.2 Procedure at local sickness fund level The patient submits “the application for reimbursement of costs by the SSF” to his local sickness fund. The sickness fund will be the only direct contact point for the patient. All information on the further treatment of his application will be transmitted to him by this local sickness fund which will – at the end – also inform the applicant on the decision taken by the SSF. The patient himself has no direct contact with the SSF services or with the other instances intervening in the administrative handling procedures of his request. The SSF applications are treated in a comparable way in the different sickness funds. Since sickness funds differ in scale, it is obvious that the large-sized sickness funds have a more differentiated and specialized organizational structure. Patients themselves are not deeply involved in the composition of their application file. They are asked to provide the necessary documents that are needed to enter a valid request for reimbursement. In most of the local sickness funds the patient will be directed towards the social service. These are mostly the administrative driver behind the further SSF procedure and are the main contact point for the patients. The handling of the patient’s request for reimbursement is divided in two different parts: The administrative handling and the handling of the medical aspects of his request.
KCE Reports 133 Special Solidarity Fund 39 The administrative part is taken care of by the social services of the local sickness funds. These services will verify if all necessary documents are available and all medical information has been entered by the patient. In order to complete the file, the social services will contact, if necessary, the health care provider (the prescribing medical doctor or the hospital where the patient is being treated). Once the patient’s file is complete, the administrative services of the local sickness fund will transfer the file to the medical department of the same local sickness fund. The medical department of local sickness funds is managed by the advising doctor(s). The focus of the action at local sickness fund level lays merely on the administrative completeness of the application file, since this is a requirement to eligibility for reimbursement. Subject-related activities, such as research on the specific disease the patient is suffering from or indications, at the level of the local sickness fund are rare. From the interviews with the medical doctors of the health insurance funds (at national level) we noticed local sickness funds have little or no standard guidelines to evaluate the validity of the patients’ request for reimbursement. At local level no specific selection criteria are taken into account. Once a demand for reimbursement has been entered by a patient, member of the sickness fund, the request will be handled and completed if necessary. The local sickness funds do not have the authority to refuse the settlement of a request for reimbursement of costs by the SSF. Even if the local sickness fund is clearly convinced the application of the patient does not meet the criteria set by the SSF and thus has no chance on being accepted for reimbursement, the local sickness fund still has to handle his request and enter it for decision by the SSF. In such a case the social services might draw the patient’s attention on the expected refusal of reimbursement by the SSF, but at the end it is up to the patient to take the final decision on whether to apply for reimbursement or not. One of the criteria for obtaining reimbursement of costs is that the applicant needs to have used all possible other rights to reimbursement by other (private of public) insurances he can benefit of. The local sickness fund will ask the patient to provide a declaration ‘on honor’ that he has no other personal rights on reimbursement and did not obtain a refund from any other private insurance and that all rights following Belgian or foreign legislation have been exhausted. In case another insurance only reimburses part of the cost, the patient has to explicit the amount eligible for reimbursement by this source. Next to the declaration ‘on honor’, the request for reimbursement needs to be composed of an information sheet, a prescription drawn up by a physician and a medical report allowing to check if the criteria of the respective reimbursement category are met and a detailed bill or an outline of the costs in case of a demand on principle. After the administrative handling of the patients’ request for reimbursement, the request will be transferred to the national level (the health insurance funds) for further treatment. Each file always includes a formal advice from the advising doctor of the local sickness fund on the validity of the request for reimbursement. Mostly this advice is focused and limited to the completeness of the application file. 5.2.3 Procedure at the national sickness funds The applications for reimbursement of costs by the SSF entered at local sickness fund level are transmitted to the national sickness funds. The patient’s application, the requested documents and the advice issued by the medical advising doctor of the local sickness fund are included into the application file. At national level the applications are reviewed from an administrative and medical point of view. At first they are treated by the administrative staff operating under the responsibility of a medical director. The number of administrative officers treating the patients’ files differs, depending on the size of the national sickness fund. The larger sickness funds mostly have different administrative officers.
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Optimalisatie van de werkingsprocessen van het Bijzonder ... - KCE

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