RESUMO
Contribution to an Internal Discussion on Quantitative and Qualitative Optimisation of Expertising Procedures: The medical advisory and expertising Services of the German statutory sickness insurance are according to German social legislation authorised to request supporting documents direct from the treating physicians or hospitals. The consultant medical expertiser for ENT diseases at Cologne worked out the percentage of requests that resulted in "further investigations" and the amount of work involved. A document form was used to record all such requests for a given period. 154 expertising procedures concerning ENT diseases were counted within a period of 5 weeks. 47% of the patients concerned pertained to workers' sickness insurance funds and 29% to guilds sickness insurance funds. Two thirds of all requests were channelled through the statutory sociomedical preconsultant service and one-third were sent by post. 55% of all the requested documents were considered to be "complete" and 45% "incomplete". N = 100 requests were initial and N = 54 were follow-up requests. The answers received were considered satisfactory and final in 62% of the requests, whereas "further inquiries" were considered necessary in n = 58 (38%) of the cases. 80% of the cases in which the requests resulted in satisfactory information, were approved for sickness insurance payment and approximately 20% were rejected. The average period of time that elapsed between a request for more information and the reply and the final expertising given to and passed on to the patient by the statutory insurance body was 2 weeks. In cases where "further inquiries" are considered necessary, three additional working days are usually required in the Cologne ENT diseases area. If the statutory sociomedical preconsultant service procedure could be intensified, this would result in better channelling of requests by the ENT medical and advisory service of the stautory sickness insurance bodies. A more pronounced examination by the statutory sociomedical preconsultant service could minimise the need for additional requests, follow-ups and "further inquiries" and could increase the speed of completion of approved or rejected insurance cases from 14 days to at the most one day or even 0 days. This pilot study was conducted to encourage the local bodies to optimise their work. In the long run good quality of work, patient satifaction and patients' job security will result and will be the corner-stones of modern quality assurance and quality management in North-Rhine Westphalian medical expertising and consultant services in association with the relevant statutory sickness insurance bodies.
