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

2. THE CURRENT STATE  7 revision departments  516 revision employees: 356 base rev. emp. (68%) 160 external rev. emp. (DPČ/DPP) 94 base rev. doctors (32%) 2

3. STRATEGY OF THE REVISION SYS 3 TEMTEM Do periodical andtimely check-ups and revisions Put emphasis onprospective benefits of controls and revisions Establish a system of quality audits Improve validations, automatical and ad hoc controls Unify the approach to work

4. TRUST BUT VERIFY 4 The goal and mission ofpast and ongoing revisions by VZP ofprocess,thus toverifythe andpaymentsofpublichealth is to verify legitimacy legitimity of reporting insurance funds. outputs,inappropriatecombinationsofoutputs,controls on sex of insured, etc.).  with the attend ance of the provider of health services- settlement agreement with data in documentation, and if there are medical reasons for a medical procedure. We check  withoutthe a ttendanceoftheproviderof healt h services-datafromtheinformationsystem(numberof

5. CONTRACTUAL PROVIDERS Poitns of ourinterest:Poitns of ourinterest: hospitalshospitals medical transportation outpacient clinics, laboratories senior houses with contract of paid health care long-term care workplaces 5

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

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

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

9. HOW A REVISION USUALLY TAKES PLACE 9  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

10. PAPERS AND PAPERS AGAIN Subject to a review in one workplace are usually tens to hundreds of medical documentation.. 1010

11. RESULTS OF YEAR 2014 11  The quantificationof misconducts that were identified in all revisions of the accounted health care in 2014 was around45 000 000 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. 18 000 000 euro. more than 24 000 revision  We have prepared reports.

12. IT IS NOT ONLY ABOUT REVISIONS… 12 The revision and control work is a broad set of activities:  we assess if the isured 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)  we assess the competence of providers during contracting the paid health services  we examine complaints about the contracted health services providers  we provide handling of requests for scientific advice within or outside the VZP ČR

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

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