NTA's audit on private clinics charges to patients insured by the National Organisation for Healthcare Services Provision (EOPYY)

Following a citizen’s anonymous complaint, a group of ΝΤΑ inspectors carried out an audit on the charges of private clinics, based in Thessaloniki, to insured inpatients of the National Organisation for Healthcare Services Provision (EOPYY), during the period 2010 - up to date.

Specifically, the "forced" upgrading of patients’ level of clinic service with a fee at an additional cost to them was observed, as well as the non-analytical recording of additional charges (beyond the amount covered by the National Organisation for Healthcare Services Provision).

The audit found, inter alia, that:

• Both the Unified Health Care Benefits Regulation and the contracts of the National Organisation for Healthcare Services Provision with private clinics do not specify a minimum number of 4 - Bedded hospital rooms for the service of its insured inpatient, nor do they provide the exemption of the insured inpatient from the cost of upgrading the level of clinic service in the absence of a 4 - Bedded room or a free bed in a 4 - Bedded room. In these circumstances, the insured patient is often induced to sign a declaration of “accommodation upgrading” and pay the subsequent costs arising from it
• The requirement for private clinics to force insured inpatients to sign, prior to their hospital admission, a Formal Declaration in which they are vaguely informed that they are likely to incur private charges, is not provided for in the provisions of the Unified Health Care Benefits Regulation, the KEN-DRG System legislation and the terms of their contract with the National Organisation for Healthcare Services Provision, since insured patients are liable only for benefits not reimbursed by the National Organisation for Healthcare Services Provision
• Usually, the Services Receipts issued by private clinics do not indicate the KEN-DRG, nor the individual charges in detail, but the total amount of the private charge of the insured patient, so that the patient is unable to check the charges
• Patients insured by the National Organisation for Healthcare Services Provision are not sufficiently informed by the Organisation on the terms and conditions of their hospitalisation in private clinics
• In one case, a medical auditor of the National Organisation for Healthcare Services Provision did not request an exemption from the audit duties (e.g. approval of hospitalisations) exercised in a private clinic in Thessaloniki, with which his/her spouse also works, in breach of the principle of impartiality

Based on the above findings, the Authority's Audit Report was forwarded to the National Organisation for Healthcare Services Provision in order to take the necessary measures to reform the Organisation’s contracts with private clinics, so that these contracts include:

• A minimum number of 4 - Bedded rooms for the service of its insured inpatients and, in case the National Organisation for Healthcare Services Provision contracts with a private clinic does not have 4 - Bedded rooms and the clinic's obligation to inform the insured patient about the required upgrade, the available options and the costs arising from them
• The prohibition of insured patient’s prior commitment - through the signing of a Formal Declaration upon admission - to accept indefinitely any charges that may arise during his or her hospitalisation, and if during the insured person's hospitalisation the need arises to provide services not provided for in the Unified Health Care Benefits Regulation, the consent of the insured patient should be required, after having been informed in detail of the additional charges
• The detailed recording in the Services Receipts of the health services corresponding to additional charges to insured patients (by the National Organisation for Healthcare Services Provision) and the obligation to provide insured patients by the National Health Insurance Fund with an itemised list of all services provided during their hospitalisation
• The exact procedure for the transfer of patients from private clinics to other public or private health care facilities, the amount of the cost and who bears the cost.

In addition, the National Organisation for Healthcare Services Provision was asked to provide its insured citizens with the possibility to be informed by phone or internet about:

• The availability of a 4 - Bedded room in private clinics contracted with the National Organisation for Healthcare Services Provision
• The terms of the contracts and the benefits to which they apply
• The legal consequences of signing the Formal Declaration - private agreements

Finally, the NTA audit report was forwarded to the President of the National Organisation for Healthcare Services Provision for disciplinary action against the doctor referred to above.