With the Second Long Term Care Reinforcement Act, the changes in nursing care, which will fundamentally change the operative implementation of long term care services in private insurances and make this more complex, come into effect on January 1, 2017. The law has been in effect for a year, but the most important changes were just enforced. Now there are five degrees of long term care instead of the previous three degrees. Starting immediately, nursing care needs are measured based on how able a person is to manage everyday activities.
The term “in need of care” was completely newly defined, plus the previous time values that were used as an orientation no longer play a role. Instead, the question is usually if the required ability is still present and if the affiliated activities can be performed independently, sometimes independently or only dependent.
This means a new level of complexity for the management of long term care services and their billing in long term care insurance.
Transition from nursing care levels to nursing care degrees
The transition into the new nursing degrees occurs automatically and is fundamentally based on the legally defined rules. Thus, those in need of care do not have to submit a new application at the turn of the year to be assigned the corresponding nursing care degree for the next year.
An additional continuance provision ensures that nobody will be worse off. Frequently even an improvement of the service received is possible - at least theoretically.
Implementation of the PSG II in the performance test
In practice, the model of all service promises and service types from the tariffs PVN/PVB on the basis of PSG II (for example, long term care allowance, day and night care (partial inpatient), prevention care, short-term care, inpatient care in connection with protection of rights) too often means - almost on a regular basis - a manual calculation in connection with the appropriate distribution to the individual nursing care groups.
As horrible as this may sound, it is frequently like this in reality as well. The amount of encountered arrears confirms that the implementation of PSG II is described as challenging by many health insurance companies. In addition to the technical complexity, the period of time from the final publication of all required information to the time of implementation on January 1 was much too short. The resulting implementation in individual establishments was therefore done under the leading aspect of operational legal capacity with service accounting and not under the aspect of the process cost resulting from this.
In order to better describe the impact assessment for the PSG II, it has proven helpful to measure and weight individual types of services (here document types) and their billing from the PSG II and then put them in relationship to the nursing care cases over the year. In the example below, 1,000 nursing cases a year mean approximately 1,500 days of billing in four years. Here it must be considered that many nursing cases have more than an expense occurring on an annual basis.
This fundamental validation sensitizes for the consequences in the service accounting of an average private health insurance company.
In the observation for the PSG II above, it must be considered that potentials for reduction were not considered and therefore should be evaluated in an additive manner. To put it simply, the use of the in|sure Health Claims long term care observed here means that with the previous observations, for each 1,000 nursing care cases, 1,500 processing days are available for other activities during the period of observation. Of course, this assessment is only an approximation of reality and does not mean that it is a real observation for an individual private health insurance company.
Automation and machine service long term care accounting are indispensable for economic sustainability
The automatic calculation of nursing care allowance including half nursing care allowance, short-term and prevention care including transitions into the respectively available service types is indispensable for efficient nursing care accounting. The automated display of used or available limits (for example, prevention care) from the individual nursing care groups has proven to be necessary and helpful.
Additionally, the administrative of open consultation that should be considered in machine-based long term care allowance accounting is a further indicator for high automation rates.
Without the assurance of a complete observation, the payment or inspection of invoices breaching commitment should be observed. In everyday business, these are distinguished by increased manual inspection requirements and the affiliated time capacities.
What automation potentials are additionally needed during this time?
After the initial burden was handled with the new in|sure Health Claims for long term care insurance, it was clear which areas have additional potential for optimization and automation.
A focus was placed on, among other things, automation when mapping compensation agreements from the private health insurance association with complex service accounting in order to determine the appropriate reduction amount for providers without compensation agreement.
Furthermore, an enhancement of the existing straight through processing is required in the following areas, among others:
- with the aid pricing for billing purposes
- with the optimization of time recording for breaks
- with the optimization of billing short-term and prevention care
What changes with the PSG III?
This article handles the impact assessment in services for PSG II. However, you should always remember that PSG II is knocking at the door.
The following main points are already known:
New rules against accounting fraud for long term care services
In order to be more effective against fraud in outpatient nursing care, the long term Care Reinforcement Act III gives health insurance companies new control rights for home-based long term care services. Starting in 2017, they should receive a systematic inspection right for outpatient service providers.
Furthermore, the inspection rights for medical services should be expanded to nursing care services for better quality assurance. Furthermore, health insurance companies will be able to inspect bills from outpatient services in the future independent of the MDK.
There will probably be a contextual adjustment for private health insurance. Altogether, it can be seen that the “fight” against fraud is receiving a significantly greater importance and thus, the question is brought up regarding which systematic infrastructure can and/or should offer support.
This will significantly increase the pressure on automated auditing and make new approaches of fraud detection necessary.