REVISION SYSTEM OF VZP ČR

OPEN HOUSEPRAGUE 4TH JUNE, 2015

ZDEŇKA SALCMAN KUČEROVÁ, M.D., MBA CENTRAL REVISION DEPARTMENT

THE CURRENT STATE

�7 revision depart ments

�516 revision emp loyees:

356 base rev. emp. (68%)

160 external rev. emp. (DPČ/DPP)

94 base rev. doctors (32%)

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STRATEGY OF THE REVISION SYS

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TEM

•Do periodical and timely check-ups and revisions

•Put emphasis on prospective benefits of controls and revisions

•Establish a syste m of quality audits

•Improve validatio ns, automatical and ad hoc controls

•Unify the approac h to work

TRUST BUT VERIFY

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The goal and mission of past and ongoing revisions by VZPof process, thus to verify the and payments of public health

is to verify legitimacy legitimity of reporting insurance funds.

outputs, inappropriate combinations of outputs,controls on sex of insured, etc.).�with the attend ance of the provider of health services- settlement agreement with data in documentation, and if there are medical reasons for a medical procedure.

We check�without the

attendance of the provider of health

services-data

from the information system (number of

CONTRACTUAL PROVIDERS

Poitns of our interest:

hospitalsmedical transportation

outpacient clinics, laboratories

senior houses with contract of paid health care

long-term care workplaces

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CONTRACTUAL PROVIDERS

Numbers:�More than 20 000 outpacient clinics

�More than 150 ho spitals (50 000 beds)

�More than 500 lon g-term care workplaces (48 000 beds)

�More than 500 pro viders of medical transportation

�More than 600 sen ior houses with contract of paid health care

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THE CONDITIONS OF EFFECTIVITY

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�Analytical support - navigation�Controllable contr act condition�Controllable paym ents rules�Stable team of qu ality revision employees

prestige of revision�Increase of social employees�Cooperation of he ath insurace companies

�Cooperation with�Cooperation with

expertsthe insured

REVISION – CONTROL WITH VISIT

�A standard revisio n team consists of1 revision doctor and 1 assistant of rev. doctor (nurse).

�A revision usually last 2 days.

�They take with th em a notebook, a copier, a printer, paper, etc.

Then they almost always find mistakes…

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HOW A REVISION USUALLY TAKES PLACE

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Revisions are usually announced in advanceProviders do not get a list of insureds for preparing all their

medical documentation in advanceWe usually review 1-4 quarters of a yearAt the workplace of the provider we prepare a record, where

we indentify what we have reviewed and describe our findings, also make photocopies of medical documentations

Then we make a protocol with assessmentIf we find out that the rules for the payment of public health

funds was not abided, we want the payment backThe disagreement with this conclusion can be expressed by

the objections

PAPERS AND PAPERS AGAIN

Subject to a review in one workplace are usually tens to hundreds of medical documentation..

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RESULTS OF YEAR 2014

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�The quantification of misconducts that were identified in all revisions of the accounted health care in 2014 was

around 45 000 000 euroBut it is not a real impact. It depends on the system of

payment of public health funds and it is displayed with delay. The expected real impact is app.

18 000 000 euro.

more than 24 000 revision�We have prepared reports.

IT IS NOT ONLY ABOUT REVISIONS…

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The revision and control work is a broad set of activities:�we assess if the i sured is entitled to the payment of public health funds for certain health services(payment for some medicaments, medical devices, health services, spa and rehabilitation etc. need the prior consent of the revision doctor)�we assess the co mpetence of providers during contracting the paid health services�we examine comp laints about the contracted health services providers�we provide handli ng of requests for scientific advice within or outside the VZP ČR

CONCLUSION

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less work ork

intensive skills,

�Tough and thank

�Very important w

�Work that needs communication arts

�There is on ongo ing nationwide debate

about the intention to separate the revision departments from the health insurance companies and to form an independent supervisory authority in the Czech Republic

�It has its pros an d cons

�We will see!

HAVE NICE STAY IN PRAGUE

Thank you for your attention and

cooperation

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