Transferring health data to healthcare insurers
Healthcare providers, such as hospitals and family doctors, are by law obliged to transfer certain health data to healthcare insurers. Healthcare insurers may use this data to process claims and to carry out checks.
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Health data and claims
The health data that healthcare providers must provide to healthcare insurers when submitting a claim is laid down in ministerial regulations.
- For example, hospitals must state a diagnosis treatment combination (DBC) when submitting a claim. This DBC is a general description of the care demand, level of care and treatment of a patient. Including the rate the hospital charges the healthcare insurer.
- Healthcare providers in mental healthcare (GGZ) state which care services (who, when, for how long) have taken place according to the care performance model (ZPM) and the characterisation of the care demand. The characterisation of the care demand takes place by a classification of groups of patients based on the quantity and severity of their complaints and problems.
If you are a mental healthcare patient and believe that passing on substantive information about your treatment to the healthcare insurer is an infringement of your privacy, you and the care provider can sign the Care performance model privacy statement (in Dutch). Your care provider must submit the invoice together with this statement to your healthcare insurer. In that case, the invoice will not include any substantive information about your treatment, such as your diagnosis or type of care demand.
Health data and formal and material checks
Healthcare insurers have a statutory task to check whether:
- the healthcare provider is allowed to provide the claimed care and whether the claim amount is correct (formal check);
- the care provided was appropriate and effective given the patient’s care demand (material check).
Healthcare insurers may process health data to carry out these statutory tasks.
Additional health data
Healthcare insurers may request additional health data from the healthcare provider when carrying out material checks. And in extreme cases, they can also view patients’ files.
This is subject to strict rules. These are set out in ministerial regulations. The healthcare insurer’s medical advisor is responsible for processing health data for material checks.