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REVISION SYSTEM OF VZP ČR OPEN HOUSE PRAGUE 4 TH JUNE, 2015 ZDEŇKA SALCMAN REVISION SYSTEM OF VZP ČR OPEN HOUSE PRAGUE 4 TH JUNE, 2015 ZDEŇKA SALCMAN KUČEROVÁ, M. D. , MBA CENTRAL REVISION DEPARTMENT

THE CURRENT STATE � revision depart 7 � 516 revision emp ments loyees: 356 THE CURRENT STATE � revision depart 7 � 516 revision emp ments loyees: 356 base rev. emp. (68%) 160 external rev. emp. (DPČ/DPP) 94 base rev. doctors (32%) 2

STRATEGY OF THE REVISION SYS TEM • Do periodical and timely check-ups and revisions STRATEGY OF THE REVISION SYS 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 hoc controls ns, automatical and ad • Unify the approac h to work 3

TRUST BUT VERIFY The goal and mission of past and ongoing revisions by VZP TRUST BUT VERIFY The goal and mission of past and ongoing revisions by VZP is to verify legitimacy of process, thus to verify the legitimity of reporting and payments of public health insurance funds. We check � without the ttendance of the provider of a healt outputs, inappropriate combinations of outputs, controls h services- data from the on sex of insured, etc. ). information system (number of � with the attend ance of the provider of health servicessettlement agreement with data in documentation, and if there are medical reasons for a medical procedure. 4

CONTRACTUAL PROVIDERS Poitns of our interest: hospitals medical transportation long-term care workplaces outpacient clinics, CONTRACTUAL PROVIDERS Poitns of our interest: hospitals medical transportation long-term care workplaces outpacient clinics, laboratories senior houses with contract of paid health care 5

CONTRACTUAL PROVIDERS Numbers: � More � More 6 than than 20 000 outpacient clinics CONTRACTUAL PROVIDERS Numbers: � More � More 6 than than 20 000 outpacient clinics 150 ho spitals (50 000 beds) 500 lon g-term care workplaces (48 000 beds) 500 pro viders of medical transportation 600 sen ior houses with contract of paid health care

THE CONDITIONS OF EFFECTIVITY � Analytical support - navigation � Controllable contr act condition THE CONDITIONS OF EFFECTIVITY � Analytical support - navigation � Controllable contr act condition � Controllable paym ents rules � Stable team of qu ality revision employees � Increase of social prestige of revision employees � Cooperation of he ath insurace companies � Cooperation with 7 experts the insured

REVISION – CONTROL WITH VISIT � standard revisio n team consists of A 1 REVISION – CONTROL WITH VISIT � standard revisio n team consists of A 1 revision doctor and 1 assistant of rev. doctor (nurse). � revision usually last 2 days. A � They take with th em a notebook, a copier, a printer, paper, etc. Then they almost always find mistakes… 8

HOW A REVISION USUALLY TAKES PLACE Revisions are usually announced in advance Providers do HOW A REVISION USUALLY TAKES PLACE Revisions are usually announced in advance Providers do not get a list of insureds for preparing all their medical documentation in advance We usually review 1 -4 quarters of a year At 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 assessment If we find out that the rules for the payment of public health funds was not abided, we want the payment back The disagreement with this conclusion can be expressed by the objections 9

PAPERS AND PAPERS AGAIN Subject to a review in one workplace are usually tens PAPERS AND PAPERS AGAIN Subject to a review in one workplace are usually tens to hundreds of medical documentation. . 10

RESULTS OF YEAR 2014 � The quantification of misconducts that were identified in all RESULTS OF YEAR 2014 � The quantification of misconducts that were identified in all revisions of the accounted health care in 2014 was around 45 000 euro But 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 euro. � have prepared We reports. 11 more than 24 000 revision

IT IS NOT ONLY ABOUT REVISIONS… The revision and control work is a broad IT IS NOT ONLY ABOUT REVISIONS… The revision and control work is a broad set of activities: � assess if the i we 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) � assess the co we mpetence of providers during contracting the paid health services � examine comp we laints about the contracted health services providers � provide handli we ng of requests for scientific advice within or outside the VZP ČR 12

CONCLUSION less work � Tough and thank ork � Very important w � Work CONCLUSION less work � Tough and thank ork � Very important w � Work that needs intensive skills, 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 � has its pros an It d cons � will see! We 13

HAVE NICE STAY IN PRAGU E Thank you for your attention and cooperation 14 HAVE NICE STAY IN PRAGU E Thank you for your attention and cooperation 14