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

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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.
KCE Reports 133 Special Solidarity Fund 41 Neither the patient nor the local sickness fund is informed on the advice issued by the medical director of the national sickness fund. They both will only receive the final decision that is taken at SSF level by the ‘College medical directors’ or by the SSF leading medical doctor (in case of delegation). 5.2.4 Process flow within the SSF 5.2.4.1 The decision-making processes on patients’ applications There are three different decision-making processes that can be used to decide on a patient’s application: • Patients’ applications treated in the plenary session of the ‘College of medical directors’. • Delegation of decision by the ‘College of medical directors’ to one member of the college (actually to the SSF leading officer that is a medical doctor) • Delegation of decision on patients’ applications towards the local sickness funds In the graph below (figure 6) the repartition between the 3 decision-making processes is shown. Figure 6: Distribution of the three SSF decision-making processes 100,00% 80,00% 60,00% 40,00% 20,00% 0,00% 2003 2004 2005 2006 2007 2008 Number of cases that was examined in plenary session of the Committee Number of cases that was examined by one member of the College Number of cases for which the autonomy of decision was delegated to the social insurance institution. Source: Annual reports of the Special Solidarity Fund 2005, 2006, 2007, 2008 The data from the SSF sample suggest that the SSF College has remained the dominant decision organ for new applications and revision of applications, while requests to extend a previously introduced (and treated) application 16 were more and more delegated to one member or, to a lesser extent, to the sickness funds (see figure 7). 16 Requests for extension of a previously treated application are treated procedurally by the SSF as new applications: the same rules and formalities apply.
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Optimalisatie van de werkingsprocessen van het Bijzonder ... - KCE

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