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.
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:
Healthcare-related documents supplied by the service provider are also checked according to the following criteria:
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).
The service provider must send the insurer a detailed and comprehensible invoice;
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:
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