The investigation highlighted several concerning issues, including the inadequate and unclear communication of information to patients covered by EOPYY, the illegal practice of “upgrading” charges during hospital stays in contracted private clinics, and the failure to follow proper administrative procedures for monitoring and sanctioning overcharging. The Ombudsman also raised concerns about the lack of transparency and impartiality in the auditing process.

Ombudsman’s recommendations

To address these findings and enhance transparency in the healthcare sector, the Ombudsman has made several key recommendations:

  1. Examine all complaints: EOPYY should urgently review all complaints regarding overcharging for hospitalisations in contracted private clinics and issue corresponding audit reports.
  2. Enforce regulations: For audit reports that confirm abusive charges, EOPYY should enforce Article 58 of the Unified Regulation of Health Benefits (EKPY) and ensure that the amounts are reclaimed from clinics that have not responded or refunded the overcharged amounts.
  3. Clarify financial obligations: EOPYY should remind clinics of the legal and contractual frameworks governing financial information provided to patients. Specifically, if a clinic lacks four-bed wards, they must accommodate EOPYY-insured patients in the next available ward without imposing additional charges due to the difference in room capacity.
  4. Investigate tax issues: EOPYY, in coordination with tax authorities, should investigate and clarify the tax implications of hospitalisation charges.
  5. Streamline audits: EOPYY should improve its audit processes and ensure that medical auditors’ actions are thoroughly reviewed to prevent impunity and restore public trust in the system.

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