1. UNAUTHORISED BEHAVIOR IN CROSSBORDER HEALTHCARE ELIŠKA DVOŘÁKOVÁ, HEAD OF INTERNATIONAL LAW DEPARTMENT PRAGUE, 4. 6. 2015

2. CONTENTCONTENT 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

3. INTRODUCTIONINTRODUCTION -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 players involved, more space for unauthorized behavior/potential fraud and corruption (legislators, healthcare providers, health insurance funds, insurees) 3

4. 4 INTERNATIONAL REIMBURSEMENT – ADMINISTRATIVE PROCEDURE (EU/EEA/SWITZERLAND, CONTRACTUAL STATES State of Insurance (ČR) Foreign Country Liaison Body (CMU) Czech health insurance fund Czech insuree with entitlement document (EHIC) Liaison Body Helping health insurance fund in EU

5. 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% 5

6. 6 REFUND OF COSTS State of Insurance (ČR) Foreign country Czech insuree 30-60 days Czech health insurance fund

7. UNAUTHORISED BEHAVIOR OF INSUREES (INDIVIDUALS) -Forgery of EHIC (entitlement 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 of business/fictive declaration of employees to be insured within public health insurance scheme necessary controls of individual payers and employers 7

8. UNAUTHORISED BEHAVIOR OF HEALTHCARE PROVIDERS Healthcare provided abroad - Principal of mutual trust, cooperation, information -Limited possibilities of control (quality of healthcare, relevance of healthcare, technical conditions and personal capacities of healthcare providers) ›Declaration of healthcare which was not performed ›More healthcare provided 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 dispose of entitlement document – healthcare provider sometimes uses the „old one“ – even if the patient is not ensured anymore IMPORTANCE OF INFORMATION 8

9. 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 healthcare 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…) 9

10. QUESTIONS and ANSWERS 1010

11. THANKYOU FOR YOUR ATTENTION