Through the transparency law for doctors, the government wants to gain more insight into the supplements charged for doctors’ ambulatory services. Below we discuss in detail what this obligation entails, how it will affect your practice, and what you can do now to be prepared in time.
What does mandatory transparency entail?
Mandatory transparency ensures that doctors who charge supplements to their patients, such as for ambulatory medical care, can clearly report these supplements to the insurance institutions. This includes:
- Supplements above the convention fee: When you charge a higher amount than the convention rate, this supplement must be explicitly stated.
- Non-reimbursable services: Costs for medical procedures that do not fall under the compulsory health insurance, such as certain examinations or treatments, must also be clearly reported.
- Costs for materials, techniques or instruments: If costs are charged for medical devices that fall outside reimbursement, these data must also be passed on.
The NIHDI offers new transparency codes / pseudocodes with which supplements or additional services can be clarified. The supplements are divided into 4 main categories:
- Category 1: Statistical transparency codes (reasons for the supplement)
- Category 2: Reimbursable, but conditions for reimbursement not met
- Category 3: Services that do not give rise to compulsory insurance reimbursement
- Category 4: Material, technique or instruments that do not qualify for reimbursement
This makes the cost structure of care delivery more transparent for the patient, the healthcare provider and the insurance institutions. It also supports the new regulations, whereby doctors will have to use adapted (pseudo) nomenclature codes to process everything correctly.
Steps of the introduction
- 1 September 2023: Obligation for doctors to clearly state all costs – including supplements – in electronic billing.
- 1 October 2024: If you use supplements in this phase, you can indicate the reason why you charge a supplement by designating one or more transparency codes.
How does this work in practice?
When you electronically bill a reimbursable consultation to the insurance institutions and you ask the patient for a supplement, you must explicitly indicate the supplement in the invoice and you can indicate the reason why you charge a supplement. This is made possible by means of transparency codes (category 1) introduced by the NIHDI:
- 384075: Supplements for a professional extra effort
- 384090: For costs directly linked to the service
- 384112: For indirect costs (costs for the premises, staff costs)
- 384134: For a supplement without any explanation
Example:
- Reimbursable service: Consultation with a specialist.
- Fee: €50 (convention rate).
- Charged supplement: €20 (above the convention fee).
- Both the fee and the supplement are stated on the invoice and passed on electronically to the insurance institutions via the correct transparency code.
In addition, you must pass on the following information for ambulatory services for which patients do not receive reimbursement:
- The amount a patient owes for a service that is reimbursable, but that does not meet the reimbursement conditions (category 2).
Example: a pluridisciplinary geriatric evaluation (code number 102233) is not reimbursed for a patient younger than 75 years, because an application rule for that code number stipulates that the patient must be older than 75 years.
- Service code: enter the generic transparency code 384215
- Related service: enter the nomenclature code of the service you would normally attest if the reimbursement conditions were met. If several code numbers with the same description are eligible, you may choose which number you state. In our example, you enter code number 102233 here.
- The amount a patient owes for non-reimbursable services because they do not exist in the nomenclature of medical services, but that have a demonstrated added value or equivalence compared to a “standard of care” (category 3).
Example:
- Service code: enter the generic transparency code 384230
- Free text field: enter a description of the service or the nomenclature code number of an existing similar service.
- The amount for material, techniques or instruments that are incidentally not included in the fee of the reimbursable service and that is not reimbursed in another way (category 4).
Example: In the context of cataract surgery, a bifocal lens is not reimbursed, unlike a monofocal lens.
- Service code: enter one or more transparency codes:
- 384156 for the material costs
- 384171 for the anaesthesia costs
- 384193 for the processing costs of the service
- Free text field: add a description of the material, technique or instruments.
- Related service: state the nomenclature code of the reimbursable service for which material, technique or instruments are billed.
From 1 October 2024, all new transparency codes and pseudocodes will be available in Mediris eFact/eAttest and Mediris Specialist.
