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

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42 Special Solidarity Fund KCE Reports 133 Figure 7: Proportion of applications in the SSF sample in function of decision organ and type of demand by year of decision (SF:sickness fund) The law provides that the King can define conditions for the delegation of the applications to one or more physician of the College. The amount, the invoice and the payment of reimbursement are criteria that can be taken into account. The decisive competence can not exclusively be exercised by a physician of the sickness fund the patient is affiliated to. Today however there are no formal rules to orient the applications to the central (College) or decentralised decision process (delegation to the SSF leading officer (medical doctor). The SSF medical doctor decides on the routine applications by delegation of the College. Decisions on what types of cases are delegated are taken by the College. These decisions are mentioned in the minutes of the meetings of the College. The policy of the SSF leading officer to whom the delegation is given, is that if there is any doubt whether the case meets the requirements of the delegation or if there is any doubt whether the application meets the criteria for reimbursement, the application will be submitted to the plenary session of the ‘college of medical doctors’. There is no formal control on the delegated decisions taken by the SSF leading officer. However, all negative decisions will always be contra signed by one member of the College. Decisions that are delegated to the (local) sickness funds are limited. Currently all EB (Epydermolysis Bullosa) files are delegated to the sickness funds since 2001. 10 In the Royal Decree, the possibility was created to further extend the delegations towards the sickness funds. This could be done by the College of medical directors. Each trimester the sickness funds have to enter a ‘financial overview ‘of the delegated decisions. The SSF medical doctor has no clear view on these cases. The application files are not transferred to the SSF services. As a consequence a full control of these delegated decisions is not possible.
KCE Reports 133 Special Solidarity Fund 43 5.2.4.2 Administrative handling of application files Once a demand for reimbursement is submitted to the services of the SSF, the application is subject to administrative control procedures. Administrative staff SSF The administrative staff of the SSF counts 3 collaborators and 1 person for the handling of mail representing 3,6 FTE. Two of the staff members treat the more difficult applications. The applications are divided between these two staff members according to the language of the patient requesting for reimbursement. Registration and handling of SSF applications The applications are registered into the SSF administrative database. At the same time they are separated in two groups: the applications to be decided by the ‘College of medical directors’ and the ones to be decided ‘by delegation’. (one member of the ‘College of medical directors’ – in reality the medical doctor in charge of the SSF). As previously explained, if the request for reimbursement is a prolongation of a medical treatment or cost that previously was reimbursed, the request for reimbursement will be decided upon by the SSF medical director (leading officer of the SSF) ‘by delegation’. The SSF administrative staff checks the files on completeness. If elements are missing, (for example the prescription of a treatment or the motivation of the medical doctor issuing the prescription, the ‘declaration on honour’, the invoices), the staff will contact the national sickness fund and ask for the missing documents or return the file for completion. The administrative staff of the SSF prepares the file for decision by the ‘College of medical directors’ or by the member of the college (delegation procedure) They enter the data from the application file into the SSF database. The information included in the database is described in table 1 in section 4.1.3. At the same time a paper sheet is completed. This sheet contains all information initially registered in the database and is used to register all elements that are important for the decision to be taken on the request for reimbursement. The administrative staff examines the case and formulates a draft decision as well as a draft motivation based on the criteria as foreseen in the SSF regulation. If a non-reimbursement decision is suggested, the administrative staff will mention the criteria upon which the suggested rejection is based. Preparing a draft decision, the administrative staff of the SSF adds information to the file on previous decisions of similar cases taken by the College of medical directors. They document the case and add relevant information to the file (for example on the prevalence of the illness, the drug prescribed…). The administrative services of the SSF keep a track of all decisions taken at SSF level. All decisions of the ‘College of medical directors’ and the decisions taken ‘by delegation’ on reimbursement are stored in a file (text file) by the administrative staff. For each application for reimbursement the administrative staff also calculates the cost of an eventual reimbursement over a one year period, in order to check if the criterion “the treatment or the medical device is expensive” is met.
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Optimalisatie van de werkingsprocessen van het Bijzonder ... - KCE

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