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

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44 Special Solidarity Fund KCE Reports 133 Suspension of handling of the application If the application has missing documents or is not complete, the administrative staff will suggest suspending the period for handling of the application. The decisions on suspension are always taken by the leading medical officer of the SSF. If there is a suspension, the application will be returned to the correspondent sickness fund (national level). Formal reasons for suspending are: • Prescription is not included • No medical record • No declaration ‘on honour’ If an invoice of medical costs is missing, the application will not be suspended; a decision on the request for reimbursement will be taken but under the condition that the missing invoice is provided. The number of cases that are suspended is limited. The sickness fund at national level will have to complete the missing ‘formal’ elements of the request for reimbursement and re-enter it to the SSF services. When arriving at the SSF, it will be treated as a new request and registered as such in the SSF database. 5.2.4.3 Medical handling After the administrative handling, the patient’s file is transferred to the leading officer (medical doctor) of the SSF. The application and the draft decision as well as the motivation are reviewed in the perspective of the SSF criteria that have to be met from a medical point of view. The leading officer of the SSF will further document the case from a medical point of view and if necessary collect additional information from medical specialists and experts on the subject to be examined. Using the file as prepared by the administrative staff, the leading officer of the SSF will check if the medical criteria as foreseen in the regulation on the SSF reimbursement are met. If the conclusion of the SSF leading officer is to suggest to grant reimbursement, the corresponding category of the criteria that are applicable considering the SSF regulation, are mentioned on the paper sheet in the file. (sheet that has been prepared by the administrative staff). If the request for reimbursement does not meet the SSF criteria, all criteria that are not met are mentioned (marked) on the back of the paper sheet. This paper sheet is an important document since all elements for taking a final decision are inventoried. This sheet also is the official document on which the final decision (delegated decision or decision from the ‘College of medical directors) will be mentioned and signed. When the decision is a delegated decision, taken by one member of the ‘College of medical directors’, positive decisions will be signed by the person taking the decision. At this moment delegation is only given to the leading officer (medical doctor) of the SSF. Delegated decisions to refuse reimbursement always will be contra signed by another member of the ‘College of medical directors’. The current practice is, that the medical director from the sickness fund to which the patient adhered to, will contra sign the decision.
KCE Reports 133 Special Solidarity Fund 45 5.2.4.4 Decisions on reimbursement by the ’College of medical directors’ Process The files that are submitted to the plenary session of the ‘College of medical directors’, are fully prepared by the SSF services. This college is composed of the medical directors (or their representatives) from each of the sickness funds and of medical doctors of the NIHDI (included one representative of the Drug Reimbursement Commission). A ‘proposal for decision’ as well as a motivation from the leading officer of the SSF is mentioned in each file. The agenda as well as all application files are sent in advance to all members of the College. There are weekly meetings of the College. A draft agenda, some accompanying documents and the minutes of the previous session are send in advance by email. The final agenda and the files from the patients are delivered to the members of the College and normally at least two days before the meeting of the College. The meetings of the ‘College of medical directors’ are chaired by the medical director of the NIHDI. The leading officer of the SSF weekly meets the chairman of the ‘College’ to prepare the meeting. The agenda and the individual cases to be discussed on the next meeting are reviewed. Meeting of the ’College of medical directors’ The agenda for the meeting of the ‘college’ is mostly well filled. Beside the SSF files, the ‘college’ has many other items to treat. From the interviews with the members of the College we understood the time for the SSF agenda is rather limited. In order to proceed rapidly, the chairman formulates a proposal for decision on each application that has to be treated. The members of the College are asked if they agree with the proposal. Every member of the ‘college’ can ask to discuss the case submitted for decision. Argumentation and additional information can be provided at the meetings. If there is no consensus, a final decision is taken by a majority of votes. Additional information regarding the price and/or the indication can also be asked to external experts. The law refers to authoritative scientific organisations, official institutions within the NIHDI, the FOD Volksgezondheid, Veiligheid van de Voedselketen en Leefmilieu/SPF Santé publique Sécurité de la Chaîne alimentaire et Environnement and the Belgian Healthcare Knowledge Centre. If no advice was given within two months starting form the demand for additional information, the College decides. The decisions are included in the minutes of the session of the College. These minutes are formally approved at the next meeting of the College. 5.2.4.5 Handling period within the SSF As shown in the table below (table 7), the average handling period within the SSF has been reduced over the years. In the SSF annual reports, it is clearly stipulated that the 2003 data are not comparable with the next years. In the graph below the results are visualized for the years 2005, 2006, 2007 and 2008 showing the total process time within the SSF evolved from 14 days to 12 days.
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Optimalisatie van de werkingsprocessen van het Bijzonder ... - KCE

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