Practice peculiarity
A practical feature can claim is in Germany, physicians (inn) e (n) from the physicians' association, if they submit a fee payable / payroll there.
background
In order to ensure the provision of medical care by contracted doctors , the health insurance companies and the Association of Statutory Health Insurance Physicians as contractual partners agree on medical group-specific case-related benchmarks as average values in accordance with Section 84 (6) and (8) SGB V. These guidelines should not be exceeded. If a doctor nevertheless exceeds the specified benchmark due to his prescription behavior, he can be sued for this. Such a recourse procedure can possibly be averted by asserting individual practical features as part of an audit.
Examples of practical features
A practice peculiarity within the meaning of the drug benchmark agreement exists in a doctor's practice if
- an above-average number of patients required particularly expensive treatment;
- an additional qualification of the doctor, which leads more patients with severe clinical pictures to this practice.
Implementation procedure
Practical peculiarities are reported to the responsible examination board as part of the hearing in accordance with Section 24 SGB X (administrative procedure). As EDP accountants, diagnosis codes according to ICD-10-GM are transmitted in the account; in the case of manual accounting, the corresponding forms must be filled out.
The following information is required as a minimum requirement:
- Master data of the patients including the health insurance company
- Primary diagnosis that triggered the costs (according to ICD-10-GM)
- As far as possible, the actual costs of drug therapy, not every serious diagnosis automatically leads to higher drug costs.
- Five times the benchmark can be used as a guideline.
The following additional information is advantageous:
- Specify other medical data such as accompanying illnesses, general condition, weight, height, etc. in codes according to ICD-10-GM classification.
- Reason (e.g. no alternative form of therapy possible, avoidance of hospitalization, etc.)
The examination board decides which practical features are finally recognized and to what extent. This can differ from examination board to examination board. Both the actually incurred, verified costs of a reported patient or an arithmetic mean value based on empirical values can be used.