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.