Prescription accounting
Under recipe accounting refers to the accounting of cash recipes with health insurance . Services are billed as part of statutory health insurance (GKV) . Parameters such as prescribed medication, identification of the insured person and the issuing doctor are recorded automatically, especially with a view to a later statistical evaluation, in order to be able to draw conclusions about a possible ( DMP- relevant) disease pattern of the patient or the prescribing habits of the doctor, for example . The provisions of data protection must be taken into account.
Statutory health insurance is organized according to the principle of benefits in kind. The pharmacies do not receive their money directly from the insured, but from the health insurance companies. Since prescription billing is very complex due to a large number of formal requirements, it is carried out by the so-called pharmacy data centers. In addition, there is also a billing of the latter with the health insurance companies or health insurance companies for direct sales by the manufacturer , provided that a cost estimate has been requested and issued beforehand . This must be submitted together with the prescription, especially in connection with a permanent prescription .
Legal basis
Relevant bases for the prescription billing towards the health insurance companies are:
- Pharmaceutical billing agreement according to § 300 SGB V
- Framework agreement on the supply of pharmaceuticals according to § 129 SGB V and
- Pharmaceutical supply contracts
The main legal basis for billing transactions with the health insurance companies is § 300 SGB V. It regulates the machine-readable transfer of the pharmaceutical central number to the prescription as well as the forwarding of the prescriptions and the billing data to the health insurance companies. The details are set out in the nationwide pharmaceutical billing agreement for Section 300 SGB V and the associated technical systems.
In addition, the framework agreement in accordance with Section 129 of Book V of the Social Code and the pharmaceutical supply contracts regulate the supply of pharmaceuticals to those insured by the health insurance companies. A basic distinction is made between contracts at the federal and state level.
Pharmaceutical supply contracts at federal level are concluded between the German Pharmacists' Association and the representatives of the health insurance providers.
Examples:
- Framework agreement according to § 129 SGB V
- Pharmaceutical supply contracts with alternative health insurances, employers' liability insurance associations, post officials, the Federal Armed Forces and the Federal Border Police
At the state level, there are pharmaceutical supply contracts with the regional health insurers. The regional health insurance funds include the local health insurance funds (AOK), the company health insurance funds (BKK), the agricultural health insurance funds (LKK), the guild health insurance funds (IKK) and the Knappschaft. The respective regional pharmacist associations are contractual partners for these cost bearers.
The drug delivery contracts regulate the basic provisions on the delivery and billing of prescriptions. Specifically, it concerns the delivery authorization, details of the delivery, the price calculation and accounting issues such as B. the type of billing, the billing and the sorting of the prescription sheets. It also stipulates the period within which a medical prescription may be delivered (usually within one month of the date of issue).
In addition, the contracts regulate the requirements for properly issued statutory health insurance regulations and contain provisions on invoice and taxation complaints.
Pharmacy data centers
The majority of the prescription sheets at the expense of the health insurances are billed via the pharmacy's or their own computer centers. There are also private clearing houses. A list of all data centers for cash registers can be found at the night and emergency service fund.
Preparation in the pharmacy
It is important to check the prescriptions to ensure that the prescription is correctly issued, as the payment can be refused by the health insurance companies for purely formal reasons. Missing information can often be added by the pharmacist himself; correction by the prescribing doctor may be necessary. The pharmacy data is then printed on the prescription sheet. The requirements for this are summarized in Technical Annex 2 of the billing agreement for pharmaceuticals according to Section 300 SGB V. The prescriptions are usually picked up from the pharmacy twice a month.
Processing in the pharmacy data center
In the pharmacy data center, the prescriptions are unpacked and registered using the so-called pharmacy institution code. The recipes are then scanned in using high-speed document readers. The speed of processing is heavily dependent on the use of standardized forms (so-called sample 16 form) and the machine-readable printing in medical practices and pharmacies.
After scanning, the recipe data is recognized by a software. All data that was not recognized automatically must then be corrected or supplemented manually. For this purpose, the scanned recipes are sent to screen workstations where data typists add the characters that were not recognized.
Invoicing and dispatch of accounting documents
After the data has been corrected, the entire database is available. The data is merged and sorted according to specified criteria.
During the entire processing process, several hundred plausibility checks ensure that the recipe data is determined without errors. Two sets of data are created for invoicing (cash register and pharmacy billing), printed out and sent to pharmacies or health insurance companies.
In accordance with the agreement pursuant to Section 300 SGB V, the cost bearers receive not only the invoice documents in paper form, but also the individual recipe data and the images in file form.
Additions and depreciations
The additions and deductions are factual or arithmetical corrections by the health insurance companies. The data centers will offset these amounts in the next possible settlement with the pharmacies. If necessary, the pharmacy can appeal against a withdrawal. The deadlines specified in the drug delivery contracts must be observed.
Prescription delivery
The last activity of a billing period is the dispatch of prescriptions to the cost units in the contractually prescribed sorting. For this purpose, the document reading systems are used again, which enable not only scanning but also the sorting of the recipes.
Other services
statistics
In addition to the monthly billing, the pharmacies receive extensive statistical evaluations. This enables the comparison of the current billing month with the corresponding values of the previous month as well as the values achieved in the current year with those of the previous year. In addition, the pharmacy values are compared with the average values of all pharmacies in the respective federal state, administrative district and district. A product group overview shows the distribution of statutory health insurance sales across the areas of prescription and non-prescription drugs as well as aids and miscellaneous. In addition, the physician statistics provide an overview of the sales development for the 30 top-selling physicians. With all this information, the statistics are an important tool for the pharmacy manager for the management of the pharmacy.
Online access
Most pharmacy data centers offer their customers the option of accessing their data online via a secure connection. The pharmacist can, for example, display his prescription delivery data or access his prescription images by entering suitable search criteria.
security concept
Insurance coverage
As an additional service, the data centers offer extensive insurance coverage for the prescriptions. This begins with the receipt of the prescription from the patient and only ends with the proper payment by the insurance provider. The prescriptions are insured along the entire process chain (pharmacy, collection service, data center).
privacy
Data protection is very important . The data centers process highly sensitive social data. Numerous security measures are intended to ensure that unauthorized third parties do not have access to the pharmacy billing data.
In February 2012, several data centers were suspected of illegally trading personal prescription data.
literature
- Andreas Lacher, Franz Schwarz: Pharmacy for practice . Ed .: Herbert Gebler, Gert Kindl. 4th edition. Deutscher Apothekerverlag, Stuttgart 2005, ISBN 3-7692-3195-3 .
Individual evidence
- ↑ Framework agreement on the supply of pharmaceuticals according to § 129 SGB V. ( Memento of the original from October 11, 2016 in the Internet Archive ; PDF) Info: The archive link has been inserted automatically and has not yet been checked. Please check the original and archive link according to the instructions and then remove this notice. on vsa.de.
- ↑ Overview of all data centers for cash registers. Retrieved November 11, 2019 .
- ↑ Suspected illegal trade in prescription data. Spiegel online, February 13, 2012, accessed July 22, 2012.
