The Health Insurance Act (KVG) and the related ordinances provide the basis for the monitoring of services and benefits, and consequently for healthcare controlling. Health insurers must check the efficiency, expediency and cost-effectiveness of the invoiced services. The service provider must supply all the information required for this purpose as well as the relevant documents (article 42, paragraph 3, KVG).
In the healthcare sector, the compulsory healthcare insurance (OKP) reimburses a portion of the costs of care and nursing services related to the diagnosis or treatment of an illness and its consequences.Up
Prerequisites for reimbursement
- Services must be provided by recognised service providers. These are nursing homes, organisations offering healthcare at home and healthcare professionals (article 35, KVG).
- The services must be efficient, expedient and cost-effective (article 32, paragraph1, KVG).
- The service provider must limit its services to a scope that is in the insured person's interests and is necessary for the therapeutic purpose. Reimbursement may be refused for services that exceed this scope (article 56, KVG).
The healthcare measures are those listed in the Healthcare Benefits Ordinance (article 7, KLV).
Additional prerequisites for reimbursement by health insurance are: a proven need, i.e. the need must be clarified (article 7, paragraph1, KLV), and a medical prescription (article 8, paragraph 1, KLV).
The insurer must examine whether:
- the statutory requirements are met;
- the tariff agreements are adhered to;
- the invoiced healthcare services have actually been provided.
Healthcare-related documents supplied by the service provider are also checked according to the following criteria:
- Efficiency: The medical services must be demonstrably suitable and achievable for the targeted therapeutic purpose.
- Expediency: The cost-to-benefit ratio between the services/benefits and the objective must be reasonable.
- Cost-effectiveness: No cheaper but equally effective and expedient alternative treatment must be available.
The Health Insurance Act authorises insurers to have sight of and process all the personal data they require to perform their remit (article 42 in conjunction with articles 84 ff., KVG).
Service provider's obligations
The service provider must send the insurer a detailed and comprehensible invoice;
- must provide all the information required by the health insurer in order to verify the calculation of the reimbursement and the cost-effectiveness of the services/benefits (article 42, paragraph 3, KVG);
- provide the insurer with an exact diagnosis or additional information of a medical nature (article 42, paragraph 4, KVG).
For the purposes of handling information required in connection with service and benefit controlling, the duty of confidentiality is governed by the Federal Law on General Provisions concerning Legislation on Social Insurances (ATSG), the Data Protection Act (DSG) and the Health Insurance Act (KVG). All Helsana employees are subject to a duty of confidentiality.
Information provided in connection with healthcare controlling is used solely for the stated purpose. After the invoices have been checked, the documents are kept in a separate and specially protected system to which only a limited number of employees have access.
Helsana meets the specific requirements for data protection:
- A comprehensive data protection concept is in place.
- All collections of data are reported to the Federal Data Protection Commissioner.
- Processing regulations are in place for the business processes.
- Our data protection officers meet the technical requirements.