Wednesday, October 12, 2016

Dispute over allegations of manipulation in the case of statutory health insurance funds – FAZ – Frankfurter Allgemeine Zeitung

In the statutory health insurance, was for a long time, a clear calculus: As an attractive, young and healthy Insured were considered special because this is the least costly. But for some time this principle seems to be undermined. Because the Insured can’t be sick enough, at least on paper. Why is that? Of course, on the money.

Britta Beeger author: Britta Beeger, editor of the economy.

it has Particularly added bluntly the just Jens Baas, the boss of the techniker Krankenkasse. In an interview with the Frankfurter Allgemeine Sunday newspaper, he accused his own and other statutory health insurance funds to manipulate for this reason, even diagnoses of patients. The cashier tried to get the Doctors to document for the patient as many as possible diagnoses, said Baas. “From a slightly high blood pressure is a serious. From a mood of depression, a real Depression, that gets 1000 euros more a year per case."

For the elderly and chronically ill patients, there is more money

to understand this, you need to deal with the risk structure compensation scheme of the health Fund. Since 2009, the health insurance companies run their entire contribution revenue on these funds, a total of around 200 billion euros. This money is then redistributed: What is the cash how much get depends on how high the costs are, the cause of their Insured. For Older more than for Younger, chronically Ill, and persons receiving disability pensions to be especially careful.

doctor Serious accusations: Doctors make patients on the instructions of the health insurance companies sicker than you are.

For a total of 80 expensive and often chronic diseases in the risk structure compensation fixed packages. The idea behind it: In the competition among the health insurance companies should have conditions same start – no target faring worse, just because she has Insured many of the elderly and sick.

health insurance companies send their consultants in the medical practices

The health insurance funds thus have an incentive that as many patients as possible are classified as the lucrative Chronicles, finally, you get a lot of money especially from the risk structure compensation. Therefore, you want to keep the Doctors to provide a complete and accurate diagnosis, either through letters or by sending them a consultant in the practice.

describes A doctor from North Rhine-Westphalia-how it works: Regular consultant to the various health insurance companies as well as the kassenärztliche Vereinigung to him and ask questions, for example: Patient X still get an Aspirin, don’t have the had a heart attack? The doctor who would not read his name in the newspaper, has neither the time nor the desire to entertain with the consultant. Meanwhile, this leaves, therefore, often a list of suggestions. “Many of them, I assume, simply because they are right, and I may have overlooked something actually,” he says. “I think it’s not frivolous and the money I get for it.”

patient should be made on the paper sicker

In this point experts agree: That Doctors give the correct key Figures, important is also the health economist Jürgen Wasem of the University of Duisburg-Essen. It does make a difference, whether a Patient has a classical Diabetes or Diabetes with eye disease. Already this approach shows, however, how big is the competition among the health insurance funds.

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The charge of the technician, the heads of Baas is now, however, that the funds are pushing the Doctors to assign either a Code for a more severe disease or a different severity that they are cheating so at the time of billing. For the Doctors the power to financially often no difference for the funds. The paid “premium of ten euros per case for Doctors, if you make the patient on the paper sicker,” said Baas. “You have to ask in the process of optimization of the coding. Some companies will visit the Doctors in person, some on call." Most frequently the diseases of the diseases, i.e. Diabetes, cardiovascular, and mental diseases.

dispute over allegations of manipulation

this statement has made Baas a lot of attention, after all, it is also a question of the money of the contributors. Other health insurers like the General local sickness funds, on which the statements of the technicians, leaders should aim to deny, to cheating on this way. The President of the German medical Association, Frank Ulrich Montgomery, has a different opinion. “This money will be columns frittered away on consultants, call center, and pull the trigger. It lacks, unfortunately, for the care of patients," he said. The legislature should not hesitate “for a long time, and consequences”. Health economist Wasen referred to the so-called “Up-Coding”, as experts call it Manipulation, “wrong, forbidden and criminal.”

That seems to be the funds but not to hold. In the past there were always accusations that you are pushing Doctors to manipulate the diagnoses of patients. The Federal insurance office, for the supervision of all the nationally active funds has pointed out, again and again, to irregularities. Of the AOK lower Saxony, subject only to their own country supervision is even known that they paid Doctors tens of euros per Patient, when you made the disease details.

so Far, all of which, however, remained without great follow. Some of the funds had to pay back to the regulatory process, although too much of the amounts received from the risk structure compensation to the health Fund and the Same again as a penalty on top of it. However, it is believed the engineer-in-chief Baas, the Problem persists. The technician should therefore give now to your own behavior an opinion to the Federal insurance office.


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