Invoice control forms a part of a health insurer’s core activities. The huge number of invoices – Helsana alone receives 16 million each year – combined with checks of the services with regard to their effectiveness, appropriateness and efficiency, require a high level of automation and a great deal of expertise. Invoice control ranges from checking individual invoices and dealing with statistics right through to preventing fraud. Progress in technology means that invoices can be checked more and more efficiently and accurately these days.
Helsana receives two thirds of all invoices electronically – straight from hospitals or practices. The other third arrives in paper format and undergoes a considerably long process before being entered into Helsana’s invoice system. That's when the actual checking process starts. The aim: to spot any tariff items or prices on the invoice that were entered incorrectly or unjustifiably on the basis of the service provider’s statement. The system contains all tariffs used by hospitals and practises to bill services. There are 100 different tariffs with more than 130,000 tariff items in total across Switzerland. Automated controls assess the digital receipt for whether the service invoiced can be covered by basic insurance or, if need be, whether the service is covered by supplementary insurance. They also check whether the items have been applied properly. A second step checks whether the invoiced items are plausible in themselves and whether they result in a consistent invoice. If a digital invoice does not pass these two checking stages, it is assessed for possible fraud. The automated settlement processes nowadays help insured persons save CHF 300 million a year in total.
In the last years, Helsana has made substantial investments in IT infrastructure, which has considerably improved the basis for data. Efficient invoicing processes and full data acquisition using sophisticated evaluation tools have become strategic competitive factors for stand-alone insurers. Nowadays, there is the possibility of using reliable tariff benchmarks, which can clearly visualise if too many services are invoiced, allowing them to be addressed.
Invoice control is becoming more and more precise. What the latest technology will never be able to do, however, is check whether the service invoiced corresponds to the medical service actually provided. Attentive patients are required for this, as they are the only ones who know which service has actually been provided.
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