Helsana's healthcare controlling procedure involves assessing healthcare benefits on the basis of the documents relating to the healthcare provided, and carrying out comparisons with the prescription and the invoice. Healthcare controlling is carried out at the service provider's premises or in the Helsana service centre.

Helathcare controlling

The basic verification criteria are identical for all healthcare controlling procedures, regardless of whether they are carried out in the service centre or at the service provider's premises. The main task of the healthcare controllers is to check the healthcare services invoiced to Helsana: Can the invoiced services be reconciled with the services that have actually been performed and documented?

To enable the best possible assessment of benefits, documentation relating to the healthcare is required. This usually comprises all the available documents, such as the prescription, clarification of needs, healthcare plan, documentation of history/progression, etc. The healthcare controller cannot assess the overall situation until he or she has all the necessary documents.

Documentation is inspected at the service provider's premises or in the Helsana service centre.

Procedure at the service provider's premises

On-site controlling is mainly carried out at nursing homes. It simplifies the administrative aspects of collaboration with the service provider.

Appointments and procedure are agreed with the service provider by telephone in advance and confirmed in writing. There is no need for a contact person from the organisation to be present while documents are being inspected. However, the contact person should be reachable for queries if necessary.

The form for the healthcare controller's classification decision is completed for the service provider on site. No documents are copied or removed without the service provider's agreement.

Procedure in the Helsana service centre

This mainly involves the examination of files from freelance healthcare professionals and organisations offering healthcare at home. However, files may also be requested from nursing homes.

The required documentation for benefit assessments is called in for forwarding to the healthcare controller. Healthcare services at home and services by freelance healthcare professionals are checked as regards commercial aspects, in the same way as nursing home services. Collaboration with the medical examiner is guaranteed when medical questions have to be considered.

All confidential documents are stored in a protected archiving system and they may only be viewed by specified individuals.

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