UNAUTHORISED BEHAVIOR IN CROSSBORDER HEALTHCARE

ELIŠKA DVOŘÁKOVÁ,HEAD OF INTERNATIONAL LAW DEPARTMENT

PRAGUE, 4. 6. 2015

CONTENT

1. Introduction

2. International payments (reimbursement between institutions, refund)

3. Unauthorized behavior of Insurees

4. Unauthorized behavior of Healthcare Providers

5. Unauthorized behavior of Health Insurance Funds

2

INTRODUCTION

-Different situation, when healthcare provided in EU (EEA, Switzerland), Contractual countries, „Third“ countries

1.EU: EU legislation – EU Regulations (No. 883/2004 and 987/2009), EU Directives (No. 2011/24/EU, on the application of patient’s rights in cross-border healthcare)

2.Contractual states (Turkey, Serbia, Montenegro, Macedonia)

principals of mutual trust, cooperation, information…

3.„Third“ countries – no international reimbursement system between institutions

-In general : more pl ayers involved, more space for unauthorized behavior/potential fraud and corruption (legislators, healthcare providers, health insurance funds, insurees)

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4

INTERNATIONAL REIMBURSEMENT – ADMINISTRATIVE PROCEDURE (EU/EEA/SWITZERLAND, CONTRACTUAL STATES

State of Insurance (ČR) Foreign Country

LiaisonBody(CMU)

Czech health

insurance fund

Czech insuree with entitlement document (EHIC)

Liaison Body

Helping health insurance fund in EU

STATISTICS

1.Czech patients abroad (EU, Contractual states), in 2014, total amount:

848.339.710,68 CZK = 30.916.170 EUR

•VZP ČR:

551.685.914,03 CZK = 20.105.171 EUR

= +/- 65%

2.Foreign patients in CR in 2014 (temporary payments by Czech Health insurance Funds), total amount :

682.449.288,30 CZK = 24.870.600 EUR

•VZP ČR:

559.448.474,93 CZK = 20.388.063 EUR

= +/- 82%

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6

REFUND OF COSTS

State of Insurance (ČR) Foreign country

Czech insuree

30-60 daysCzech health insurance fund

UNAUTHORISED BEHAVIOR OF INSUREES (INDIVIDUALS)

-Forgery of EHIC (en titlement documents) - unauthorized (illegal) profit of healthcare (obligation of Health Insurance Fund to cover the costs = damage caused by a person = material profit of a person)

international/national system of recovery of debts

-Refund of costs of healthcare provided abroad – claiming the refund twice (public health insurance fund + private/commercial health insurance fund)

VZP ČR asks for original documents

-Fictive foundation o f business/fictive declaration of employees to be insured within public health insurance scheme

necessary controls of individual payers and employers

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UNAUTHORISED BEHAVIOR OF HEALTHCARE PROVIDERS

Healthcare provided abroad- Principal of mutual trust, cooperation, information

-Limited possibilitie s of control (quality of healthcare, relevance of healthcare, technical conditions and personal capacities of healthcare providers)

›Declaration of heal thcare which was not performed

›More healthcare pr ovided when patient is a selfpayer (refund of costs by her/ his health insurance fund later, in her/his home state)

– Q of relevance/necessity of such healthcare (considering the medical status of patient)

›Patient do not disp ose of entitlement document – healthcare provider sometimes uses the „old one“ – even if the patient is not ensured anymore

IMPORTANCE OF INFORMATION

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UNAUTHORISED BEHAVIOR OF FOREIGN HEALTH INSURANCE FUNDS

Principal of mutual trust, cooperation, information

es = EU standard forms (E125) – lack of-International invoic information

-Controls/revisions are (?) made by „helping“ health insurance fund

-declared healthcar e does not correspond with the entitlement document (more healthcare than necessary, planned healthcare without previous authorization…)

VZP ČR controls (economic department) – where suspicion for unauthorized behavior (repeated healthcare, high amounts invoiced…)

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QUESTIONS

and

ANSWERS

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THANK YOU FOR YOUR

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