What is changing in 2015?
In addition to the purchase of foot care within the chain by the care group, in 2015 foot care may also be contracted outside the chain directly from the health care provider via the policy rule Other medical care. Especially for those situations where the DM-foot is not contracted through the care group or the hospital/partnership (as part of a foot-DBC), the health care provider will in many cases want to contract the care directly from the podiatrist on the basis of the policy rule issued by the NZa ‘Other medical care (policy BR/CU-7100)’.
The podiatrist will then in turn, within the framework of cooperation and task differentiation, set up agreements with pedicures.
Where at present the (already or not diagnosed in your case) Simms classification is leading for reimbursement from the basic insurance, from 1 January 2015 reimbursement will take place based on care profiles. A health profile is a sort of ‘care burden package’ which is related to the risk you run of getting wounds through poor healing and the risk of amputation.
From 1 January 2015, the podiatrist will perform a coordinating role in the feet health care and create an individual treatment plan. This ensures you efficient and effective bespoke foot care, removing both the causes of risk factors in getting a wound and determining the number of required foot treatments.
What does this change (contracting of foot care outside the chain) mean for you?
You have diabetes mellitus and your GP, practice nurse, or podiatrist have determined that you have a low, medium or high risk of a wound (the so-called Simms classification). In that instance, it is important to have a profile assigned to get care and visit the podiatrist. Following extensive research, established according to protocol, the podiatrist determines your health care profile (care burden) and then establishes a personal treatment plan for you. The podiatrist agrees this plan with the GP and when necessary with the pedicure and keep your medical record with regard to diabetic foot care up to date.
Costs and fees
Your personal care profile is a requirement in order to qualify for reimbursement of your DM foot care in 2015.
In the case of care profile 1, only the annual dedicated foot examination is reimbursed from the basic insurance. The Dutch healthcare authority (NZa) has determined a maximum tariff.
Starting from care profile 2, the fee for specialist foot care (treatment) will be funded from the basic insurance*.
In the case of care profile 2, there is a Simms 1 with a medical necessity or a Simms 2 without increased pressure.
When the treatment only concerns personal care, this will no longer be reimbursed from the basic insurance.
When the podiatrist directly claims the care from the health care provider or the care group, your podiatrist, depending on the profile, will receive a flat fee for each patient that is known to her/him. This is regardless of the number of treatments because some patients need more care than others in order to achieve the same objective.
Out of the amount the podiatrist receives, she/he will then for instance pay the costs that the pedicure has incurred in your treatment. You will receive no invoice itself.
As of 1 January 2015, are you still receiving treatment from a pedicure and has no personal treatment plan and care profile been established by the podiatrist? Your treatment will no longer be reimbursed from the basic insurance.
* For care profile 1, after the annual dedicated foot examination (comes under the basic insurance) has taken place, reimbursement of the treatment will be done from the supplementary insurance. For a comprehensive overview, have a look ate www.3d-vcn.nl/vergoeding
Other foot care and additional insurance in 2015
VFor the other foot care not covered by the basic insurance, in 2015 you will also receive a reimbursement from your health care provider. The height of this reimbursement depends on your supplemental insurance and varies from one insurer to the next. This applies for instance to the supply of podiatric soles. The excess is not applicable in this case.