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

40 Special Solidarity Fund KCE Reports 133
The administrative control merely concerns the completeness of the application file. If
documents fail, or information is missing, the administrative staff will contact the local
sickness fund to complete the file. Some national sickness funds use a self developed
checklist that is based on the criteria for reimbursement set out by the SSF, others only
use the official application form.
The application file has to be transferred to the College of medical directors (at SSF
level) within 30 days after the introduction at the local sickness fund. If a file is
incomplete, this of course will affect on the period needed to process the file. Since the
handling period is one of the criteria that influence the overall funding of the
administrative costs of the national sickness funds by the NIHDI, the sickness fund will
‘suspend’ the period for treatment of the application until the missing elements or
documents have been provided by the applicant. In some cases, the medical
administration of the national sickness fund will directly contact the prescribing doctor
or the hospital or medical centre where the patient is treated in order to obtain the
missing elements.
Once the administrative control is completed, the files are transferred to the medical
director of the national sickness fund. For all national sickness funds, but one, the SSF
files are handled by a single medical director. For one of the national sickness funds,
there are two medical directors involved, treating separately the applications for the
Dutch speaking members of the sickness fund and these of the French and German
speaking members. These medical directors all are as well a member of the ‘College of
medical directors’ at the SFF level. The practical consequence is that they mostly will
have to decide (as a member of the College at the SSF level (cfr. Infra), on the
applications they treat, and advice upon, at the level of the national sickness fund.
As will be illustrated further in this report, treatment by the ‘College of medical
directors’ is one of the three possible decision-making processes at SSF level for
applications for reimbursement.
The medical director will examine the file and, if adequate, add additional information
on the case, taking into account the criteria to be met for reimbursement by the SSF.
Additional information mostly refers to medical information on the rare disease the
patient is suffering from, the indications, or on the treatment, the medical device or the
drug prescribed by the patient’s doctor.
The medical director from the national sickness fund formulates an advice (positive or
negative) to the SSF on each separate dossier, using the SSF criteria on reimbursement.
He is not bound by the advice from the medical doctor from the local sickness fund.
The medical director will not transfer the application to the College medical directors if
it concerns (art. 25 septies §2):
• Travel costs or costs of stay during a hospitalization in Belgium of a
patient or the accompanying person;
• Some costs as room supplements, honorarium- and price supplements,
co-payments and comfort costs The co-payments that were not taken
into account for the calculation of the MAB ceiling, as well as the delivery
margin and the safety margin for costly implants however are eligible for
reimbursement to chronically ill children under 19 years old (see also
above).
• Medical costs, costs of stay or travel costs for care abroad which the
medical advisor did not consented to;
• Interventions provided more than 3 years before the application.
As at local level, no SSF applications are rejected at national level since the patient is the
sole party to decide on the introduction of a demand for reimbursement. Even if the
advice from the medical director of the sickness fund is negative, the application still will
be transferred to the SSF.