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. The first DBC trajectory lasts a maximum of 90 days. If your treatment lasts longer, the medical specialist will open a follow-up DBC. The start date of the follow-up DBC always follows the closing date of the previous DBC. It, therefore, says nothing about when you were in the clinic yourself. A follow-up DBC lasts a maximum of 120 days. The duration of a DBC can be shorter than 90 or 120 days if a biopsy or surgery has been performed. The DBC then closes 42 days after the biopsy or surgery.

Important: Hospitals and/or Polyclinics will send the bill to the health insurer or to the patient, no more than 90 days (first trajectory) or 120 days after opening of the sub-trajectory. 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 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.