AOK launches transparency offensively: huge differences between health insurers – the economy

Which health insurance company will wait the longest for the approval of benefits? Where is the highest risk of rejection? Which provider has the most problems with their customers, such as the highest level of opposition? And why are there still no reliable comparison options for such performance parameters – despite the constant incurrence of real-quality competition, in which the mere amount of the additional contribution should no longer play an important role?

So far, there has been no major report on the transparency of performance at the box office. Only a few insurance companies – such as Siemens-BKK, Viactiv or IKK Südwest – have voluntarily published transparency reports. But that may change now, as the AOK community issued a signal shortly before Christmas and also joined forces with its nearly 27 million policyholders to launch a transparency offensive. Since then, all eleven AOKs have provided detailed information about their work, benefits, and feedback from their members via the Internet. And lo and behold, the trip is quite productive: Even in this regionally expanded health insurance network, there are huge differences in waiting times and rejection rates.

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In the east, AOK insured persons wait six times longer for a nursing bed

Need some examples for 2019? In the southwest of the republic, insured persons had to wait for approval of treatment by mother or father and child five times longer than in the east. For applicants from Baden-Württemberg, the processing time was on average 52.4 days, in Saxony-Anhalt it was on average after ten days. It was the other way around with bed care applications. Here, AOK shone in the southwest as the fastest box office in the network, 3.8 days were enough for it to make a decision. AOK Plus people in need of care had to wait six times longer, an average of 23.2 days.

On the other hand, AOK Nordwest took most of the time with dental prostheses, with treatment and cost plans submitted there averaging 18.2 days. AOK Bremen managed the processing in 4.2 days. In the case of initial applications for long-term care insurance benefits, the insured had to wait the longest with the AOK in Westphalia, Lippe and Schleswig-Holstein, where the decision lasted an average of 42.6 days. AOK Plus only needed 22 days to do this. And when it came to approving short-term care and preventive care, AOK Nordwest ended at the bottom with 20.2 and 18.6 days, respectively. In Saxony and Thuringia, local health insurance required only four and five days, respectively.

It is also interesting to process applications for inpatient rehabilitation, which should monitor the hospital stay as soon as possible after certain operations and diagnoses. AOK Nordost policyholders have the worst cards here; the processing of their applications took the longest, 25.8 days. AOK Bayern managed it in an average of 4.4 days.

Rejection rate between 2 and 29 percent

Are such differences in waiting times okay? Legally yes. And because AOKs do not compete with each other and other competitors do not publish transparency reports, even the quietest local health insurance funds hardly have to fear that members will run away from them. “However, patients must be able to rely on all health insurers to process their claims for benefits legally and clearly and to process them within the legal deadlines,” said Claudia Schmidtke, a representative of the Federal Government’s patients. By law, insurance companies must decide on applications for benefits within three weeks and, if experts are called, within five weeks.

“Excessively long and unjustified waiting times are unacceptable from my point of view and, above all, from the patient’s point of view,” explains CDU politician Schmidtke. Therefore, “it is explicitly stated that the service is considered approved after the deadline if the health insurance company does not sufficiently extend the extension of the deadline”. If the insured person has procured the necessary service himself after the expiry of the period, the health insurance company must pay the related costs. A special regulation applies to the determination of the need for care, which must be decided within 25 working days. In urgent cases – for example, if hospital care is not guaranteed – the assessment period will be reduced to one week. “If the long-term care insurance fund decides too late and is responsible for the delay, it usually has to pay the insured person 70 euros for each week of exceeding the deadline,” says Schmidtke.

Some would like to wait longer if they have a guarantee that the requested benefit will be approved. In fact, there are also huge differences in rejection rates – as the AOK comparison shows. For care benefits, it was between 2 percent (AOK Plus) and 21.6 percent (AOK Bremen) in 2019. The range for dental prostheses was 0.4 (Baden-Württemberg) to 8 percent (Lower Saxony) and for rehabilitation services 13.8 (Bremen) to 29 percent (Hesse). And the level of opposition was also different. For health insurance, it ranged from 0.05 percent (AOK Baden-Württemberg) to 0.23 percent (AOK Nordost) and for long-term care insurance from 0.96 percent (AOK Rhineland-Palatinate / Saarland) to 3.7 percent (AOK Sachsen Stop).

Fund selection may not play a role in providing benefits

Such differences could not really be explained, says Maria Klein-Schmeink, a spokesman for the Greens in the Bundestag for health policy. In their view, many chronically ill or disabled people with special care needs “would be very useful if there were a case-oriented case of care and permanent contact persons with special knowledge”. Whether or not a service is approved should “not depend on the health insurance company with which there is an insurance relationship,” Schmidtke’s patient representative emphasizes. “The legal entitlement to benefits must be fulfilled in the same way for all insured persons.” It becomes problematic when the impression is created that benefits are incorrectly rejected.

Schmidtke says that only health insurers can provide information on specific reasons that underlie different rejection rates. However, AOK data showed “how valuable a comprehensible comparison of the performance of health insurance companies can be.” In this way, insured persons “would, for the first time, have the opportunity to better assess the quality of the health insurance company’s work before a specific case of benefits,” the official said. “The question of whether and how quickly health insurers actually provide services when needed could thus become a decisive criterion when deciding for or against a health insurer.” In this regard, the AOK welcomed the “extraordinary” approach. It is “a step in the right direction that other health insurers should follow.”

The Greens are calling for a transparency portal for all

Information on the scope of benefits and the quality of benefits provided by individual health insurance companies is still “difficult to access or impossible”, regrets Schmidtke. Even officially, only individual data would be recorded, such as the number of overruns for benefit claims. Therefore, she recently contacted all statutory insurance companies to find out if other health insurers had now decided on appropriate transparency campaigns. The results of this survey will be announced publicly this year.

A real cash comparison can only work if everyone participates according to the same rules, says green expert Klein-Schmeink. “Otherwise, the courage to be transparent can lead to disadvantages because the individual data cannot be combined.” So why for a long time there was no transparency portal where processing times, rejection rates, objection procedures and similar criteria for solving the Insured were processed. are people recorded and visible to all? The corresponding Greens’ parliamentary initiative “unfortunately failed due to coalition factions,” Klein-Schmeink recalls. With the currently planned “Health Care Further Development Act” (GWeG), there would be “a new opportunity in parliament to address this issue”.

Consumer advocates: Legal requirements are needed

The Federal Association of Consumer Organizations (VZBV) is even clearer. Transparency reports are “just a step in the right direction,” said health expert Petra Fuhrmann of Tagesspiegel Background. “However, the voluntary commitment of individual health insurers does not provide consumers with the necessary opportunities for transparency and comparison when choosing a health and long-term care insurer.” thus, insured persons can quickly and easily compare the quality of individual health insurance companies.

The patient’s representative, on the other hand, refers to self-administration. The National Association of Statutory Health Insurance Funds “has a legal mandate to decide on the organization of competition in the quality and profitability of health insurance funds and to issue guidelines for establishing and conducting targeted comparisons of performance and quality benchmarks,” Schmidtke told Tagesspiegel Background. “In my view, binding indicators and criteria for comparing quality could be well defined in this task by the National Association of Statutory Health Insurance Funds to facilitate the implementation of transparency measures for health insurers.” Should be complemented by an appropriate transposition deadline. “

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