ABSTRACT
A medical consultant advises his company such that the persons insured receive the medically necessary benefits agreed in their insurance contract and thus are offered very good medical treatment. But it is also in the interests of all those insured to identify those treatments that are neither indicated, effective, nor medically necessary, as well as treatments which may prove dangerous to patients or result in overtreatment. Based on a representative sample, the present study examines which sums are not reimbursed due to this approach. The medical fields to be considered in particular are also addressed. It was found that the medical necessity of artificial insemination, alternative treatments, medications, innovative treatment methods and debatable cosmetic treatments, and certain other fields of consultation, would be worth investigating in particular. About 7 million could have been saved in 2014 as a result of the advice from the medical consultant.
Subject(s)
Cost Savings/economics , Health Care Costs , Insurance Claim Review/economics , Insurance, Health, Reimbursement/economics , Referral and Consultation/economics , Unnecessary Procedures/economics , Germany , Insurance, Health/economicsABSTRACT
BACKGROUND: This study deals with the task areas of the medical consultant in private health insurance. Although insurance medical consultation for the insurance business originated in the 19th century, the tasks and competencies of the medical consultants are still mostly unknown. METHODS: This study is a complete inventory count of all insurance medical consultation requests for the year 2013. All of the 5493 insurance medical consultation requests have been evaluated. RESULTS AND DISCUSSION: Most of the consultation requests concern the medical necessity for medical drugs, followed by the medical consultation of alternative medicine and the classification of cure and rehabilitation measures of hospital medical treatments. The need for insurance medical consultation on lifestyle drugs, cosmetic operations and artificial insemination has increased significantly in the past 10 years. Since 2009, moreover, the need for medical consultation on the subject of "Ruhensleistungen" with regard to non-payers and "Notlagentarif" has strongly increased.
Subject(s)
Insurance, Health/statistics & numerical data , Practice Patterns, Physicians'/statistics & numerical data , Private Sector/statistics & numerical data , Referral and Consultation/statistics & numerical data , Germany , Insurance, Health/trends , Practice Patterns, Physicians'/trends , Private Sector/trends , Referral and Consultation/trends , Surveys and QuestionnairesABSTRACT
There have been medical consultants in the insurance business since the 19th century. Still the tasks and competences of the medical consultants in private health insurance in Germany are more or less unknown to the public and among doctors. There are only few publications about this topic. All questions submitted to the medical consultant from 1 January 2011 to 31 December 2011 have been examined and classified. Most of the questions to the medical consultant concern the medical necessity of medications, with life style medication playing an especially important role. Alternative medicine, the classification of cure and rehabilitation measures of hospital medical treatments, out-patient operations, new treatments, the length of hospital treatments and out-patient psychotherapy, medical consultation on artificial insemination and cosmetic surgery intervention give more and more reason for a consultation of the medical examiner. The discussion considers the details of individual insurance medicine blocks of consultation in insurance medicine and explains their significance.
Subject(s)
Insurance, Health/organization & administration , Insurance, Health/statistics & numerical data , Private Sector/organization & administration , Private Sector/statistics & numerical data , Referral and Consultation/organization & administration , Referral and Consultation/statistics & numerical data , Surveys and Questionnaires , Germany/epidemiologySubject(s)
Complementary Therapies/methods , Immunologic Deficiency Syndromes/diagnosis , Immunologic Deficiency Syndromes/therapy , Stress Disorders, Traumatic, Acute/diagnosis , Stress Disorders, Traumatic, Acute/therapy , Complementary Therapies/education , Costs and Cost Analysis/economics , Financing, Personal/economics , Germany , Humans , Immunologic Deficiency Syndromes/economics , Immunologic Deficiency Syndromes/immunology , Insurance Claim Review/economics , Stress Disorders, Traumatic, Acute/economics , Stress Disorders, Traumatic, Acute/immunology , Unnecessary Procedures/economicsSubject(s)
Goiter/therapy , Hypothyroidism/therapy , Thyroid (USP)/therapeutic use , Animals , Capsules , Female , Germany , Humans , Insurance Coverage , Middle Aged , National Health Programs , Risk Factors , Swine , Thyroid (USP)/adverse effectsSubject(s)
Cosmetic Techniques/trends , National Health Programs/statistics & numerical data , Vulva/surgery , Esthetics , Female , Germany , Humans , Informed Consent/legislation & jurisprudence , Insurance Coverage/legislation & jurisprudence , Malpractice/legislation & jurisprudence , Mass Media , National Health Programs/legislation & jurisprudence , Unnecessary Procedures/statistics & numerical dataSubject(s)
Athletic Injuries/therapy , Electric Stimulation Therapy , Insurance Coverage/legislation & jurisprudence , Leg Injuries/therapy , Muscle, Skeletal/injuries , National Health Programs/legislation & jurisprudence , Soccer/injuries , Germany , Humans , Male , Middle Aged , Patient Education as Topic/legislation & jurisprudence , Rupture , Unnecessary ProceduresSubject(s)
Health Services Misuse/economics , Magnetic Resonance Imaging/economics , Magnetic Resonance Imaging/statistics & numerical data , Mass Screening/economics , Mass Screening/statistics & numerical data , Tomography, X-Ray Computed/economics , Tomography, X-Ray Computed/statistics & numerical data , Germany , Health Services Misuse/statistics & numerical data , HumansSubject(s)
Antioxidants/economics , Antioxidants/therapeutic use , Breast Neoplasms/economics , Breast Neoplasms/therapy , Heme/analogs & derivatives , Insurance Coverage/economics , Insurance Coverage/legislation & jurisprudence , National Health Programs/economics , National Health Programs/legislation & jurisprudence , Orthomolecular Therapy/economics , Aged , Antioxidants/adverse effects , Drug Approval/legislation & jurisprudence , Evidence-Based Medicine/legislation & jurisprudence , Female , Germany , Heme/adverse effects , Heme/economics , Heme/therapeutic use , Humans , Infusions, Intravenous , Orthomolecular Therapy/adverse effects , Orthomolecular Therapy/legislation & jurisprudence , Secondary PreventionSubject(s)
Complementary Therapies/economics , Insurance Coverage/legislation & jurisprudence , National Health Programs/legislation & jurisprudence , Naturopathy/economics , Periodontitis/economics , Periodontitis/therapy , Adult , Germany , Guideline Adherence/economics , Guideline Adherence/legislation & jurisprudence , Humans , MaleSubject(s)
Acupuncture, Ear/methods , Needles , Prostheses and Implants , Acupuncture Points , Acupuncture, Ear/economics , Ear, External , Germany , Guideline Adherence/economics , Guideline Adherence/legislation & jurisprudence , Insurance Coverage/economics , Insurance Coverage/legislation & jurisprudenceSubject(s)
Acupuncture/methods , Acupuncture/trends , Evidence-Based Medicine , Homeopathy/methods , Homeopathy/trends , GermanyABSTRACT
In Germany about 300,000 to 400,000 people are suffering from Morbus Parkinson at present. It is one of the most common neurological diseases both in Germany and in Europe as a whole. With the rising number of elderly people in our population, the number of Parkinson patients will strongly increase as well in future. About 20% of these patients are already in an advanced stage. This stage leaves its marks with motor and non-motor sequelae. With the minority of these patients oral medication is ineffective. For these relatively rare cases an indication for an L-dopa-infusion therapy (duodopa pump), an apomorphine pump therapy or a deep brain stimulation may exist. The indication for one of these 3 therapy forms is given by the neurological clinic in agreement with the patient and is only given in case of failure of oral medication. All 3 therapy options are very expensive. In case of the deep brain stimulation, close cooperation between the neurologist and the neurosurgeon as well as with the patient is necessary. Experts warn about a transplantation of stem cells because there are no clinical studies and only partial clinical improvement with severe side effects are known. The transplantation of stem cells for advanced Morbus Parkinson is not a medically necessary treatment at present.
Subject(s)
Antiparkinson Agents/administration & dosage , Deep Brain Stimulation , Parkinson Disease/therapy , Administration, Oral , Apomorphine/administration & dosage , Cross-Sectional Studies , Drug Resistance , Humans , Infusion Pumps, Implantable , Levodopa/administration & dosage , Neurologic Examination/drug effects , Parkinson Disease/diagnosis , Parkinson Disease/epidemiology , Population DynamicsABSTRACT
Acupuncture originates from China and has developed out of Traditional Chinese Medicine (TCM). Since the 1970s acupuncture has been carried out more and more in Germany - especially within the context of pain-relief therapy. Acupuncture is more or less considered to be a medically necessary measure in the case of chronic knee or back pains and of chronic headaches, even if the German Acupuncture Trials (GERAC) leave some issues regarding its effectiveness unresolved. Less known is the fact that acupuncture is not only used for pain-relief therapy, but that a lot more indications have emerged over the last 20 years. Acupuncture is increasingly used for the treatment of allergies, asthma bronchial, addictions, tinnitus, but also to stimulate pregnancy and against adipositas, neurodermitis and a lot of other diseases. The available statistics state that acupuncture is used in appr. 20% of all cases for indications apart from pain-relief therapy. There are about 150 indications for which acupuncture is used as a therapy. However, for the majority of the apparent indications no proof is available in the sense of medical studies of an acceptable scientific level. Very often acupuncture has mild side-effects and rather rarely serious side-effects or health hazards. Patients are fequently not informed about them sufficiently.