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

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.