DRG & German Medical Fee Index
Diagnosis Related Groups (DRG)
The remuneration of hospital services provided on an inpatient basis should not be underestimated in terms of its economic significance for hospitals and represents one, if not the most important, source of revenue. Against the background of the significance of this source of revenue, efficient, results-oriented DRG management is all the more important as this is the only way to ensure the cash flow required for the liquidity of hospital operators.
Efficient and results-oriented DRG management requires not only comprehensive documentation of the medical and non-medical service and appropriate primary coding, but also flexible and prompt medical controlling in the event of abnormality and incorrect occupancy checks, etc.
Medical controlling not only has to observe the strict deadline regime of the PrüfvV, which will be somewhat eased with the PrüfvV 2017, but must also argue in the so-called “objection procedure”, soon to be referred to as “subsequent procedure” in accordance with Section 9 PrüfvV 2017, not only with medical but also with legal expertise.
If hospital treatment appears reasonable from a medical point of view, it is at the same time “necessary” within the meaning of Section 39 (1) sentence 1 SGB V.
We offer hospital owners advice and support in the extrajudicial and judicial assertion of hospital reimbursement claims; this in the objection procedure, from 2017 in accordance with § 9 PrüfvV 2017 “Nachverfahren”, in that we provide medically and legally substantiated opinions on the report of the MDK and the decision of the health insurance company and in the lawsuit procedure, in that we sue for the reimbursement claims or defend against unfounded reimbursement claims.
Vergütung für psychiatrische und psychosomatische Leistungen (PsychVV) Renumeration for psychiatric and psychosomatic services (PsychVV)
Up to now, psychiatric and psychosomatic hospitals have received daily rates for their services, capped by individual hospital budgets.
Hospital individual Budgets
Politicians would like to move away from this payment system with the aim of establishing a flat rate per case system in the area of psychiatric and psychosomatic inpatient care as well. The protests, some of which were fierce, have led to the decision not to introduce a budget system analogous to the DRG system. At present, it looks as if hospital-specific budgets based on previously negotiated budgets will be introduced; however, nothing has yet been finalized.
Renumeration systems …
Irrespective of this forward-looking question of practical relevance for hospital operators as to which specific remuneration system is implemented, billing audits, in particular occupancy error audits, by health insurance funds have long been part of everyday life and will remain so, also irrespective of the remuneration system.
In order to ensure cash flow, which is also essential for psychiatric and psychosomatic hospitals, the medical controlling department must, as in the case of DRG hospitals, not only ensure comprehensive documentation and appropriate primary coding, but also observe the time limit regime of the applicable PrüfvV and conduct the objection procedures, soon to be referred to as “follow-up procedures” in accordance with Section 9 PrüfvV 2017.
Psychiatric and psychosomatic hospitals
We offer psychiatric and psychosomatic hospitals our advice and support in the extrajudicial (opposition proceedings, from 2017 “post-trial proceedings”) and judicial assertion of claims for reimbursement or defense against unfounded claims for reimbursement.