This audit protocol is derived from the legal framework surrounding Health Insurance, the Health Care Market Regulation Act, the Code of Conduct for the Processing of Personal Data by Health Insurers endorsed by EUCARE, and the Material Audit Protocol of Zorgverzekeraars Nederland.
01.
Purpose and basis of audit
EUCARE is authorised, in accordance with the provisions of the Health Insurance Act, the Health Care Market Regulation Act, and related regulations, to audit the declared care and/or medical devices as supplied by the healthcare provider/institution.
In addition to its social obligation to make every effort to control the level of claims, EUCARE has the statutory task of ensuring that the Health Insurance Act is properly implemented. This ensures premium and cost control. Within this framework, monitoring the provision of (the efficiency and/or quality of) care and claims submitted by healthcare providers is appropriate.
EUCARE performs formal and substantive checks. Formal checks focus on preconditions, such as whether the insured was covered and whether the care provider is contracted by EUCARE. Substantive checks include the verification of the care provided.
In addition to its social obligation to make every effort to control the level of claims, EUCARE has the statutory task of ensuring that the Health Insurance Act is properly implemented. This ensures premium and cost control. Within this framework, monitoring the provision of (the efficiency and/or quality of) care and claims submitted by healthcare providers is appropriate.
EUCARE performs formal and substantive checks. Formal checks focus on preconditions, such as whether the insured was covered and whether the care provider is contracted by EUCARE. Substantive checks include the verification of the care provided.
02.
Safeguarding the confidentiality of personal data
EUCARE handles personal data, including the medical data assessed during a check-up, with care. In doing so, EUCARE acts in accordance with the Code of Conduct for the Processing of Personal Data by Health Insurers. The requesting and assessment of (medical) data is carried out with due observance of the principles of proportionality and subsidiarity.
For the purpose of the audit, EUCARE requests only personal data that is necessary for that audit. EUCARE will use the requested data solely for the audit purpose and not for any other purpose. EUCARE maintains records of the audits it performs to enable accountability and review by supervisory authorities. In this regard, EUCARE will ensure that only personal data which is necessary for this purpose is retained on record.
For the purpose of the audit, EUCARE requests only personal data that is necessary for that audit. EUCARE will use the requested data solely for the audit purpose and not for any other purpose. EUCARE maintains records of the audits it performs to enable accountability and review by supervisory authorities. In this regard, EUCARE will ensure that only personal data which is necessary for this purpose is retained on record.
03.
Which methods does EUCARE use in the planning and execution of substantive audits?
In accordance with the ministerial regulation and the substantive audit protocol, EUCARE has drawn up a substantive audit plan. This audit plan describes how EUCARE has set up the substantive audit (use of audit instruments) and how it carries it out (plan of approach). The authorised agent, Aevitae BV, performs the substantive audit on behalf of EUCARE.
The guiding principle in relation to the deployment of a control instrument is “that no heavier or more intrusive instrument be deployed than is necessary given the specific circumstances of the case and is justified in connection with the protection of the insured’s privacy”. EUCARE applies the most effective method of material verification for each investigation, and continuously seeks new methods to improve the effectiveness of the material verification.
EUCARE accounts for how this statutory task has been fulfilled within its annual implementation report.
The General Control Plan for Material Inspection and Appropriate Use can be consulted here.
The guiding principle in relation to the deployment of a control instrument is “that no heavier or more intrusive instrument be deployed than is necessary given the specific circumstances of the case and is justified in connection with the protection of the insured’s privacy”. EUCARE applies the most effective method of material verification for each investigation, and continuously seeks new methods to improve the effectiveness of the material verification.
EUCARE accounts for how this statutory task has been fulfilled within its annual implementation report.
The General Control Plan for Material Inspection and Appropriate Use can be consulted here.
