PubMed · 127820
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W R Halliday. Letter: Impact on experts.. https://pubmed.ncbi.nlm.nih.gov/127820/
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The borderlines between the areas of competence of the German compulsory health insurance authorities and their Medical Service can be drawn as follows: 1. The German compulsory health insurance body is legally obliged to clarify the facts concerning a patient and his illness. It is therefore imperative for the health insurance body to prepare the ground in each individual case in such a manner that the case in question can be entrusted to a doctor called upon to write an expertise, but the final decision in respect of the insurance coverage rests exclusively with the health insurance body. 2. The Medical Service system is component for helping to find the fact that must be known before the administrative procedure to arrive at a decision is initiated. The expertise given by the Medical Service is a decision help invaluably important on the grounds of specialist knowledge, knowledge of facts and experience gathered from medical practice. Wherever the borderlines of such competencies are overstepped, there is a risk of errors occurring in the expertise and in the administrative decisions based thereon. Such sources of error can be eliminated only if both parties know and accept their limitations and also do not expect the other side to cross these boundaries.
One of the tasks of the Medical Service of the compulsory health insurance system in Germany is to conduct follow-up examinations if an employee has been unfit for work for a prolonged period. This involves problems of expertise that are discussed in the present article from the viewpoints of definition, problems and psychological skill in the handling of each individual case. Good interaction between all the parties concerned proves to be an important factor to ensure sociomedical effectivity and to relieve tensions.
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