How to organise a SF?

Preparing the administrative infrastructure of a sickness fund:

Two types of preparation are needed to ensure a suitable administrative infrastructure – training staff and setting up structures and procedures.

Basically, the internal organisation of a sickness fund has to cover following procedures:

  • registration of the sickness fund’s members
  • advising members about entitlements to benefits
  • processing and checking claims
  • planning and organising health care services
  • selecting and negotiating with health care providers
  • verifying invoices for conformity with contractual benefit regulations and that there is contract with provider
  • developing a clinical information system to record the diagnosis and treatment given and for use in claim payments
  • paying invoices
  • monitoring health care providers (prescription behaviour, quality control, accreditation, etc.)
  • personnel administration, training, staff development and organisation
  • financial management and planning
  • accounting
  • statistical analysis of activity and use of information

The development of an internal structure and the assignment of administrative tasks must take into account:

  • the needs of its members
  • local circumstances
  • the existing infrastructure and local political structures
  • the need for efficiency and cost containment
  • the motivation and qualification of the staff

A decentralised organisational structure provides more direct information about residents, ensures that claims are processed properly and allows more effective control over providers.