2021-2022 Jurisdiction: the evidence of careless declaration in healthcare.
In healthcare, there are crucial points of cooperation between government, healthcare institutions such as health insurers, healthcare providers and patients. When mistakes are made, they can lead to serious consequences: from medical acting with care or not, to financial consequences and even to legal proceedings.
Arriving at court rulings is difficult for several reasons. The type(s) of illness(es), the types of medical action and, increasingly, the question of whether practitioners are claiming costs correctly, must be taken into account.
A judge must be able to make a judgment based on qualitative and quantitative facts and to judge whether those facts are based on valid and reliable research. In the sense of decision-making, in the case of legal proceedings the validity and reliability of the evidentiary techniques used and their results are central. Statistics and Algorithms (mathematics and logic) play a decisive role in this.
In this case involving legal proceedings, some of the ‘Brus decision techniques’ were used.
Mr. B. van der Kamp / Lawyer
In a healthcare case, a healthcare institute initiated proceedings
In a healthcare case, a healthcare institute instituted proceedings against a healthcare provider for false declarations.
Several criteria of care and reliability played a role in that case, which ultimately resulted in an alleged and substantial recovery amount.
Partly due to the use of the aforementioned techniques, the defendant was not convicted.
In legal proceedings it was a question of facts and the chance that a judgment would do justice to the situation at hand. The Dutch Healthcare Authority (NZa) uses a 95% reliability rate for fraud investigations, among other things.
The matrix below was not used in the proceedings in question, but the impact was used, as it is visible in the matrix: Realization concerns the (mathematical) reliability of a matrix object and Priority the ‘weighted importance’.
The combination leads to the RP-Index® which indicates the degree of usefulness for a final judgement about a certain case. To the left of the matrix, the underlying ‘variables’ are shown as they were discussed in the procedure.
(NZa) Judgment criteria
– Accuracy
– Validity
– Reliability
(MC) Material Control
– Assessment of the quality of the control.
– Representativeness of the claims sample.
– Independence of the sample and of the material reviewer.
(P) Patient Survey.
– Judgmental ability of patients about their treatment.
– Reliability of the patient survey.
– Representativeness of the patient sample.
(BM) Benchmark of claimant healthcare providers.
– Validity of the Bench Mark.
– Reliability of the Bench Mark.
– The reliability of the ‘signal’ about alleged ‘incorrect claiming’ and the legitimacy of starting a material audit
It may be clear that due to the claimant’s failure to meet the criteria of the NZa and the material control, the claim could not be awarded.
