Achmea overzealous inspector general finds that “too many visits travels” and “too much declares” … Doctor counting after yourself and come to very different conclusions
Health insurers do regularly investigate claims from doctors if they differ from the average. Looking for fraud they control the practices with the highest turnover. If they are not satisfied with how the practice justifies the declaration own behavior, they want access to patient records. That breach confidentiality. It takes practice, hours of work and they dictated what ‘normal’ is care. GP Chantal van der Zandt describes her experience with the ‘care’ into journal Medisch Contact.
“In early April 2014, I receive an email from insurer ZV:. ‘Announcement physical control” I had never heard of.
“With the help of a general risk assessment, we have considered the declaration behavior of a broad group of GPs. In this analysis examined five risks (…) On the basis of these five risks, we have a top 50 practitioners selected that we approach these physical check. You are one of the GPs who belongs to this top 50 where we have found a practical variation either high cost of claims, based on the above risks which we can not explain. “”
The health insurer that Van der Zandt sends letter Achmea, its preferred health care provider ie one who has the most local policyholders.
Health insurers such as Achmea are legally obliged to ensure the affordability and accessibility of care. Through a physical check keys they afterwards whether the care is provided legitimate and effective. That means that if the insurer think has been a doctor too often to visit a terminally ill patient, he or she is therefore called on the carpet.
Quantity over quality
You can imagine what consequences this has for care in the future. Perhaps the doctor thinks next year: “Yet but less frequently visits accountable to this patient.” An assessment of the costs which are not qualitative but quantitative and financial analysis of care delivered (“claims”) principle is also asking GP Chantal van der Zandt himself, that’s patients do not benefit?
In the case of GP Chantal van der Zandt was not even talk of a visit abnormal pattern, or too many claims. They found that Achmea miscalculated:
“I get a strong suspicion and enable an expert, a statistician. He confirmed my suspicion. I come at different figures than [Achmea]. For 2012 and 2013 calculates [Achmea] an ‘overshoot’ and possible claim of nearly 15,000 euros. According to my own verifiable calculation is the same period within the standard declared. ”
When Van der Zandt conversation enters into with the auditors – after they first had to make a written statement while she was on maternity leave – be its efforts to justify itself also once used against her:
“Especially my detailed response to the first letter ‘fell’ and they have perceived as’ fixed something to hide.” It confirmed to get that [Achmea] -controleurs have not even read my piece in preparation for the interview, baffles me .
According ZV there are only two options: there is deliberately or unintentionally inaccurate declared incorrectly declared. The possibility that there declared correct, but more care is delivered than average, is not accepted. Then swept my notes and explanations of the table with “Drift insufficiently explained. ‘”
The doctor refuses a proposed repayment, because she is convinced that she has done nothing wrong. So here’s a detail control, where patient data retrieved and secrecy is broken.
Finally give the inspectors to:
“My conclusion on the miscalculation and Applied Statistics I lay on the table. In the ZV controllers cheeks redder. […]. It is suggested that they may have done wrong to anyone. There will be the next day with the own statistician is required. And if it is true indeed, making it for me off the wick, to ZV. ”
Van der Zandt get after 6 weeks notice that additional analyzes will be performed. Achmea promised in March 2015 to come back to her.
Achmea promises to do internal research and possibly also with other aggrieved providers to the table:
“[…] Achmea deeply regrets the perception that lady from Zandt has kept to the exported material control and will announce the details get in touch with her. Achmea strives for pure performance of the control tasks it has within the health care system. It is never the intention to care institutions and / or individuals to treat unjustly or unfairly. ”
Medical Contact: “The tone of the letter I get the feeling all to be condemned”