Specialist Care Billing & DBC

Seeing a specialist doctor at the Polyclinic or in Hospital

If you require specialist medical care and you have Dutch insurance, your GP will be the one to refer you to get such care. The billing system for Polyclinic or Hospital care works differently to that of GP’s, and is based on a DBC system.

A diagnosis-treatment combination (DBC)- is a nine-digit code describes the total hospital activities (diagnostics, treatment and checks). The DBC provides information about the entire treatment process.

DBC are used within specialist care as well as mental health care (GGZ). The doctor or practitioner determines which DBC will be issued. All performances that can be declared are expressed in so-called DBC (or DOT) care products. There are approximately 4,400 DBC care products.

Foreign health insurers often request a statement/invoice that itemizes the costs of care for each medical activity. In other words: a cost breakdown. Unfortunately, IHCH is not able to abide by this request because specialist invoices are arrange differently in the Netherlands.

Why are there DBCs?

The government wants to stimulate market forces in healthcare to a certain extent. The current DBC system offers possibilities for this, because:

•     Hospitals and health insurers can negotiate with each other about the price and quality of care and treatments. The consumer can ultimately benefit from this.
•     There will be more transparency in the costs of certain treatments, so that hospitals can optimize their business operations and continue to provide affordable and effective care.

How does a DBC care product work?

If someone needs specialist care, not every action, such as the physical consultation, ultrasound, laboratory, an injection, CT scan, MRI or X-ray, will be charged separately. You could see these products as a package of care forms that are used in a specific treatment, for example for a hip fracture, irregular menstrual period, acne, or asthma. The costs of a treatment, or a DBC care product, are based on the average costs for the respective treatment. It is not a total of the costs for the activities, but is based on the average costs that are incurred when treating a patient.

The DBC healthcare product price is officially determined at the end of the treatment. This product price does not have a cost breakdown. Nederlandse Zorgautoriteit (NZA), the supervisory body for all the healthcare markets in the Netherlands, determines which DBC healthcare products hospitals and polyclinics can declare. It is possible for a patient to have more than one healthcare product at once if he/she is being treated for more than one ailment by different or the same specialist/s.

What does the health insurance company reimburse? How much the patient or health insurance policy ultimately has to pay to the hospital depends on the following factors: How much the average treatment costs when diagnosed and the severity of the treatment. For example, is it necessary to have the patient stay overnight in hospital or can he go home quickly after treatment? Whether or not surgery is required? How many visits the patient made to the specialist?. All the above information is recorded and the rate is determined on the basis of this. Afterwards, the hospital will charge the rate of the care process to the health insurer. The patient may then receive a bill for the deductible.

What information does a DBC care product contain? A DBC contains all the activities of a hospital and a medical specialist that are the result of a specific care demand. This includes:   

• The diagnosis of a specialist   
• Treatments   
• Follow-up (if applicable)
  

Getting billed for your specialist treatment
A DBC remains open for a maximum of 120 days. For outpatient non-operative treatments, the duration is 90 days. However, this only applies to the first process for a new care demand. All follow-up programs (outpatient and non-surgical) have a duration of 120 days. A DBC can even be open for 365 days for the GGZ. Important: Hospitals will send the bill to the health insurer, no more than 120 days after opening the subproject. In some cases, the bill is sent to the patient. For certain expensive medicines and treatments it sometimes happens that the costs are declared immediately after treatment, but more often you will be charged once the DBC is closed. Therefore keep in mind that it can take months before you receive the bill for specialist or hospital care.

Your deductible (eigen risico) and DBCs

Non-emergency specialist treatment is first charged to your deductible. Once your deductible is used up, you will be reimbursed according to your policy cover.