From who can join the General Healthcare System (GeSY) to how payments are audited, the Health Insurance Organisation (HIO) is set to gain broader powers and the ability to impose stricter penalties. Two amending bills would allow it to refuse new providers, audit payments up to 12 years back in cases of fraud, and impose fines of up to €600,000.
Age limit for GeSY providers
The Ministry of Health is once again proposing an upper age limit for doctors and other health professionals, this time seeking to establish in law the ability to apply it.
The provision concerns those who provide, or wish to provide, services within GeSY. No specific age is set, as the decision will be taken by the HIO.
The measure is a restriction on participation in the System, not a ban on practising medicine.
It is only one of the significant changes included in the two amending bills, which aim to give the HIO a freer hand by expanding its powers over the admission and monitoring of providers, the management of payments and the imposition of sanctions.
Limits on new providers
The biggest change in the monitoring of providers is the HIO’s ability to determine the needs of GeSY and, where specific public interest grounds apply, to refuse registrations or contracts.
It will also be able to impose terms and restrictions even on providers already under contract.
These decisions must respect the principle of proportionality and be linked to meeting needs, the quality of services, public health or the financial sustainability of the System.
In addition, the Organisation will be able to refuse or cancel the registration of professionals working on behalf of providers if they do not meet the legal requirements. Procedures are also provided for readmission after a registration is cancelled or a contract terminated.
Fines of up to €600,000
On sanctions, the maximum administrative fine rises from €30,000 to €300,000 and, for repeat offences, can reach €600,000.
For certain criminal offences, the prison sentence increases from three to four years and the fine from €8,000 to €75,000.
Audits of payments
The bills also introduce audits of paid claims going back three years, extended to 12 years where the breach involves fraud.
The HIO will be able to recover amounts paid in breach of the rules, as well as inspect premises and obtain copies of documents and electronic records.
Checks on clinical guidelines
Particular weight is given to a provision allowing the Organisation to check not only whether contractual obligations were met, but also whether clinical guidelines, protocols and safety and quality standards were applied.
To investigate possible breaches, the bills provide for gathering information and taking statements from those involved. They also introduce the possibility of settling breaches.
Medicines outside approved lists
There are also changes for beneficiaries. Providers are expressly prohibited from asking patients to pay third parties for covered services, beyond the legal exceptions.
The bills also allow, on a named-patient basis and under certain conditions, the supply of medicines and medical devices not included in the approved lists. This also applies to products that are on the lists when the patient does not meet the approved protocol.
Replacement of personal doctors
The bills also regulate replacements for personal doctors. The HIO will pay the doctor on whose list the patient is registered, with no additional payment to the replacement, while doctors will be able to agree compensation between themselves.
Oversight within the HIO
Another significant provision is the creation of an independent Internal Audit Unit, whose staff will not be allowed to perform other operational duties, in order to protect its independence.
The unit will be overseen by an Audit and Public Governance Committee, which will assess findings, risks and the functioning of the Organisation’s internal mechanisms.
The package also includes provisions on rehabilitation services, palliative care and imaging centres.
