[The challenge of auditing by medical health insurance inspectors: development of individual case inspections according to 275ff SGB V]. / Herausforderung: MDK-Prüfung: Entwicklung der Einzelfallprüfungen gemäss 275ff SGB V.

ABSTRACT

BACKGROUND: The German DRG (diagnosis-related groups) system has changed since the inauguration in 2005, whereby written inquiries and on-site auditing have been carried out by the medical inspection service for health insurance companies (MDK). Modifications in the G-DRG system are reflected in changes in the MDK visitations. This article describes exactly how these examinations have changed over time. In order to achieve this all auditing reports were evaluated. RESULTS: In the beginning correct coding and documentation were the most interesting items for the health insurance fund inspectors. Nowadays, length of in-patient treatment and specific points relating to current changes in the G-DRG system are being questioned. All areas of the hospital have now been examined during this period. There was no change in the loss resulting from the regular examinations over the years. However, the effort and input of manpower are extremely high. CONCLUSIONS: To cope with the changes in the German DRG system hospitals have to be flexible. The experiences with the regular MDK visitations can positively influence hospital organizational structures.