This control protocol is derived from the legal framework regarding the Healthcare Insurance (Zorgverzekeringswet), Healthcare Market Regulation Act and the Code of Conduct for the Processing of Personal Data by Health Insurers and the Physical Control Protocol for Health Insurers in the Netherlands.
Purpose and basis of control
EUCARE is authorized, in accordance with the provisions of the Healthcare Insurance Act, the Healthcare Market Regulation Act and related regulations, to monitor the declared care and/or medical aids as provided by the care provider/institution.
In addition to its social obligation to manage the amount of the claim, EUCARE has the legal task of ensuring that the Health Insurance Act is properly implemented. This is how premium control and cost control are achieved. Control of the implementation of (the effectiveness and/or quality of) care and declarations by the care providers fits within this framework.
EUCARE carries out formal and material controls. Formal control focuses on preconditions such as whether the insured person was insured and whether the care provider was contracted by EUCARE. Material control involves checking the care provided.
Guaranteeing confidentiality of personal data
EUCARE handles personal data carefully, including the medical data that is assessed during the audit. EUCARE acts in accordance with the Code of Conduct for the Processing of Personal Data by Health Insurers in the Netherlands. The retrieval and assessment of (medical) data take place in accordance with the principles of proportionality and subsidiarity.
For the purposes of the audit, EUCARE only requests the personal data that are necessary for that audit. EUCARE will only use the requested data for the control purpose and not for other purposes. EUCARE records the checks it has carried out to enable accountability and review by supervisors. EUCARE will thereby ensure that only those personal data that are necessary for this purpose are stored.
What methods does EUCARE use in planning and performing physical controls?
According to the ministerial regulation and the material control protocol, EUCARE has drawn up a material control plan. This control plan describes how EUCARE has set up material control (use of control instruments) and how this is implemented (action plan). The authorized agent Aevitae B.V. performs the material control on behalf of EUCARE.
The starting point for the deployment of a control instrument is “that a heavier or more invasive instrument is not used than is necessary given the specific circumstances of the case and is justified in connection with the protection of the privacy of the insured person”. EUCARE applies the most effective method of material control per investigation. EUCARE is constantly looking for new methods to improve the effectiveness of material control.
Every year, EUCARE reports in the implementation report (uitvoeringsverslag) on how this legal task has been implemented.
The General Control Plan for Material Control and Appropriate Use can be consulted here.