Performance audit (healthcare)

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In statutory health insurance law , the performance audit is an instrument to monitor the fulfillment of the contractual medical , contractual psychotherapeutic and contractual dental obligations in accordance with Section 75 (2) of Book V of the Social Code (SGB V). In addition to the freezing order to have doctors' associations to health insurance companies to take over the guarantee that the contractual medical care meets the legal and contractual requirements (§ 75 para. 1 sentence 1 SGB V) and to monitor the contractual medical activity in the sequence.

According to Section 106 of the Social Code Book V, the profitability of contract medical care is monitored through advice and testing of medical and medically prescribed services.

monitoring

According to § 106 SGB ​​V, the statutory health insurance companies and the (dental) medical associations are obliged to monitor the economic efficiency of the contractual (dental) medical care. This means that it must be checked whether the economic efficiency requirement according to § 12 SGB ​​V has been complied with. Additional legal regulations must be observed here, such as B. §§ 2, 27, 72 and 75 SGB V. Regulations can also be found in the regional inspection agreements and supra-regional framework specifications or guidelines.

Monitoring is carried out by the independent examination bodies, the examination office (until 2007, the examination committee ) and the complaints committee ( preliminary proceedings within the meaning of Section 78 SGG ), which are formed jointly by the statutory health insurance companies and the associations of statutory health insurance physicians.

As a result, measures such as advice, fee reductions or recourse can be decided.

Test methods

The statutory standard test methods for the performance audit of the supply, which are the test methods of first choice, are:

  • Benchmark tests as an abnormality check: doctor-related test of medically prescribed services if the benchmark volumes are exceeded in accordance with Section 84 SGB ​​V. The tests when the benchmark volumes are exceeded must be carried out for a period of one year.
  • Random sampling: doctor-related examination of medical and medically prescribed services on the basis of doctor-related and insured-related random samples, which include at least 2 percent of the doctors per quarter. The size of the sample according to sentence 1 No. 2 is to be determined separately according to doctor groups. In addition to the volume of services submitted for billing, the examinations according to sentence 1 no. 2 also include referrals, hospital admissions and findings of incapacity for work as well as other services initiated, in particular complex medical-technical services; Fee-based limitation regulations have no influence on the exams. The time period to be taken as a basis is at least one year.

There are also other types of abnormality checks to consider: On the one hand, checking the other damage on the basis of the federal shell contracts (§ 48 BMV-Ä, § 44 EKV). On the other hand, the state associations of the health insurance funds and the associations of the substitute funds can optionally agree on further tests of medical and medically prescribed services according to average values ​​or other doctor-related types of tests (e.g. individual examination or vertical comparison) together with the associations of statutory health insurance physicians at the state level; Insured-related data may only be collected, processed or used in accordance with the provisions of Chapter 10.

Economic efficiency requirement

In view of the relative scarcity of financial resources in the health care system, those involved in the health care system (patients, health insurers and service providers such as the medical profession) are required to use the resources available to them sparingly and economically. Numerous regulations in the form of laws, guidelines, etc. have been issued to regulate costs in the healthcare system. One of the most important regulations is set out in Section 12 of the Social Code Book V under the term economic efficiency requirement , which must be observed by those involved:

“The services must be sufficient, appropriate and economical; they must not exceed what is necessary. Services that are not necessary or uneconomical cannot be claimed by the insured, the service providers may not provide and the health insurances may not approve. "

- § 12 Abs. 1 SGB V

The term economic efficiency is defined as follows:

According to the general legal opinion, statutory medical care is economical if the statutory health insurance provider provides the necessary, sufficient and appropriate services with the lowest possible expenditure of 'costs' (in the sense of health insurance expenses). If the doctor has several equally effective and beneficial alternatives for a therapy recognized as necessary for a certain indication, the contract doctor should choose the 'cheapest' option. "

- Jens Flintrop: Lexicon: Economy . In: Deutsches Ärzteblatt , 2004.

The terms appropriate , sufficient and necessary are defined as follows:

  • It is advisable to take a medical measure that is objectively suitable for working towards the intended purpose, namely the healing success.
  • Services are sufficient if they are adapted to the individual case, correspond to the generally recognized state of medical knowledge and take into account medical progress. The performance must be sufficient to achieve the desired healing success. The service provider or service initiator is obliged to consider their actions in terms of quantity. The school grading system can be used for clarification.
  • Needed is a treatment that does not go beyond the scope of what is indispensable for the maintenance or restoration of health in individual cases. Everything is necessary that the doctor cannot do without when treating a patient according to the state of medical knowledge, otherwise the treatment is not sufficient.

If the criteria aim appropriately and sufficiently to ensure that nothing less happens than is necessary to achieve the healing success, the criterion necessary should ensure that nothing more happens than corresponds to this goal.

Legal tension

The economic feasibility requirement under social law (compliance with which is checked with the performance audit) is in tension with the civil law liability standard for medical treatments, according to which the doctor / dentist has to carry out his treatment according to the latest medical knowledge.

Medicines and medicinal products budget

These are quantity limits for the area of ​​drug prescriptions and therapeutic products regulations. These can vary from state to state.

Deadlines

A four-year limitation period applies to the performance audit . If a performance audit is only announced but not carried out within the four-year limitation period, no further recourse may be established. The course of the 4-year period is not inhibited by an unfounded test announcement .

literature

  • Beate Bahner : Fee reductions, drug regression, remedy regression. Doctors in performance auditing. Springer, Berlin 2006, ISBN 978-3-540-31320-5 .
  • Beate Bahner: Profitability audit at dentists. Avoid fee cuts - ward off recourse. Springer, Berlin 2006, ISBN 978-3-540-23691-7 .
  • Klaus Oehler: The dentist in performance auditing, argumentation aids, strategies, BEMA-Z positions . 3. Edition. Deutscher Zahnärzte-Verlag, Cologne 2009, ISBN 978-3-7691-3366-0 .

Web links

Individual evidence

  1. ↑ Eichenhofer, Koppenfeld-Spies, Wenner: Commentary on the Social Security Code V, 3rd edition 2018, § 75 no. 30th
  2. ↑ see § 106c SGB ​​V (inserted by the GKV-VSG 2015); Text of the performance auditing regulation
  3. ^ Jens Flintrop: Lexicon: Economic efficiency .  ( Page no longer available , search in web archives )  Info: The link was automatically marked as defective. Please check the link according to the instructions and then remove this notice. In: Deutsches Ärzteblatt , Volume 101, No. 6, 2004, pp. A-372 / B-316 / C-308, accessed on April 11, 2017.@1@ 2Template: Toter Link / aerzteblatt.de  
  4. ^ Judgment of the Federal Social Court of May 29, 1962, Az. 6 RKA 24/59.
  5. ↑ Economic efficiency requirement . Lexicon of the AOK Federal Association , accessed on April 11, 2017.
  6. ^ KBV advanced training . Issue 9, as of 1996.
  7. ↑ Raddatz - WKR.
  8. ↑ Federal Social Court (BSG), judgment of August 15, 2012 (Az .: B 6 KA 45/11 R).