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Minimal Organization: BRENVIA KRANKENKASSE, Gesetzliche Krankenkasse (Körperschaft des öffentlichen Rechts) – das Gelände im Modell von schräg oben

シミュレーション · Minimal Organization · Public authorities

Health insurer

A statutory health insurer as a walkable model: how a wheelchair application moves from quote to decision, when the medical service steps in and where deadlines get tight.

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All data are fictional and the deadlines simplified. The model can be adapted to your insurer's real data and filled with what is not visible anywhere today – for example deadline compliance per month, or turnaround times of medical service assessments.

This health insurance process simulation shows the fictional BRENVIA KRANKENKASSE, a German statutory health insurer with six buildings and 20 departments. Insured people and employers govern it themselves, the law sets the deadlines – and between application and wheelchair stand casework, assessment and the medical supply store.

After a stroke, the GP prescribes a wheelchair; the supply store measures and sends a quote. If it arrives electronically and matches the contract, the system approves it at once. Otherwise a caseworker checks entitlement, contract and price, queries the supplier or calls in the medical service. Target: decided within three weeks, or within five weeks if the medical service reviews and the insured person is told in time. The statutory deadlines are simplified in the model.

Sickness benefit after six weeks of illness, payment and review of hospital bills, and objections up to the objections committee run alongside. The page is written for executive and administrative boards, division and team leaders, HR development and trainers.

A wheelchair is applied for

  1. 01

    Supplier sends prescription and quote: After a stroke the GP prescribes a wheelchair; the supply store measures and sends the quote.

  2. 02

    Electronic quote: automatic check: The electronic quote is checked against the contract and the medical aids directory.

  3. 03

    Mail intake: scan and assign: Paper arrives at the scanning centre and is filed to the record.

  4. 04

    Local office: hand in and get advice: The husband hands in the application at the local office and gets advice.

  5. 05

    Medical aids casework: The clerk checks entitlement, contract and price – and whether a cheaper model suffices.

  6. 06

    Query to supplier or practice: Query: the seat width is missing from the quote.

  7. 07

    Notice: the medical service reviews: The insurer notifies: the medical service reviews, the deadline extends to five weeks.

  8. 08

    Medical service assessment: The medical service assesses whether the wheelchair is necessary and suitable.

  9. 09

    Decision after the assessment: With the assessment the insurer decides.

  10. 10

    Notice and approval: Notice to the insured, approval to the supply store.

  11. 11

    Supplier delivers and fits: The supply store delivers the wheelchair and adjusts it.

  12. 12

    Billing with the supplier: The supply store bills the insurer electronically.

  13. 13

    Supplied.

  14. 14

    Refusal with notice of appeal rights: Refusal with reasons and notice of appeal rights.

  15. 15

    Refused.

How a health insurer can use the model

  • Internal communication

    From the eleven-storey head office to the city centre branch: the collaboration view shows how benefits, contracts, billing and customer centres are connected.

    対象Executive board, corporate communications, managers

  • Onboarding

    New staff in medical aids and travel costs see the full path of an application: from the quote through automatic checking to the supply store that delivers and bills.

    対象New caseworkers, customer advisers

  • Training

    Social insurance trainees play through a flu wave or overload the medical service and see when the five-week deadline gets tight.

    対象Training, apprentices, students

  • Explaining to insured people

    What happens to my application, and why can it take five weeks? The model shows insured people, relatives and supply stores the three paths: automatic, casework, medical review.

    対象Customer centres, branches, insured people

  • Strategic overview

    Automatic approval, casework, sickness benefit team, review rate: the model weighs deadlines against costs. The ‘Flu wave’ disruption shows sickness benefit cases rising while part of the staff is off sick too.

    対象Executive board, administrative board

What is shown – why – for whom

表示内容 なぜ 対象
‘How a case flows’ diagram: automatic, casework, medical review なぜShows the paths of a medical aid application. 対象Executive board, benefits division
‘Where the time goes’ diagram: waiting for the medical service なぜShows when the deadline gets tight. 対象Medical aids team lead
‘What each control does’ diagram: electronic quote, casework, sickness benefit team, review rate なぜRanks levers for deadlines and costs. 対象Executive board, administrative board
‘Where it gets tight’ diagram during a flu wave なぜShows sickness benefit and staff under pressure at the same time. 対象Workforce planning
‘Who leads whom’ diagram: administrative board, executive board, divisions なぜExplains self-government. 対象Training, representatives of the insured
Backlog per team (resources view) なぜShows where applications wait. 対象Team leaders
Process ‘A hospital bill is paid and reviewed’ なぜShows payment before review. 対象Billing, hospitals

Departments in the model

  • Administrative board (self-government)

    Elected in the social elections, insured and employers: adopts statutes and budget, elects and supervises the executive board.

  • Objections committee

    Volunteers from self-government decide on objections.

  • Executive board

    Full-time, runs the insurer and represents it.

  • Internal audit

    Independently audits processes, payments and contracts.

  • Data protection officer

    Free of instructions: watches over health data.

  • Finance and controlling

    Budget, allocations from the health fund, payment runs.

  • HR, organisation and facilities

    Posts, training, building and canteen.

  • IT and data centre

    Member and benefits system, data exchange, app.

  • Mail and scanning

    Scans every letter and files it to the electronic record.

  • Member service and local offices

    Advise in person, accept applications.

  • Phone and online customer centre

    Phone, chat, app – most questions arrive here.

  • Membership and contributions

    Employer reports, family insurance, voluntary members.

  • Medical aids and travel costs

    Decides on wheelchairs, hearing aids, prostheses – within statutory deadlines.

  • Sickness benefit and case management

    Pays after six weeks of illness and supports long cases.

  • Long-term care fund

    A separate fund under the same roof: care levels, care allowance, services.

  • Rehabilitation and prevention

    Spa treatments, rehabilitation, parent-child programmes.

  • Contracts and care management

    Contracts with supply stores, hospitals and doctors; prices and quality.

  • Hospital billing

    Pays hospital bills on time and has anomalies reviewed.

  • Billing of doctors, drugs and aids

    Checks and pays the bills of the providers.

  • Objections office and legal

    Prepares objections for the committee and represents the insurer in court.

All processes in the model

A wheelchair is applied for

  1. 01Supplier sends prescription and quote: After a stroke the GP prescribes a wheelchair; the supply store measures and sends the quote.
  2. 02Electronic quote: automatic check: The electronic quote is checked against the contract and the medical aids directory.
  3. 03Mail intake: scan and assign: Paper arrives at the scanning centre and is filed to the record.
  4. 04Local office: hand in and get advice: The husband hands in the application at the local office and gets advice.
  5. 05Medical aids casework: The clerk checks entitlement, contract and price – and whether a cheaper model suffices.
  6. 06Query to supplier or practice: Query: the seat width is missing from the quote.
  7. 07Notice: the medical service reviews: The insurer notifies: the medical service reviews, the deadline extends to five weeks.
  8. 08Medical service assessment: The medical service assesses whether the wheelchair is necessary and suitable.
  9. 09Decision after the assessment: With the assessment the insurer decides.
  10. 10Notice and approval: Notice to the insured, approval to the supply store.
  11. 11Supplier delivers and fits: The supply store delivers the wheelchair and adjusts it.
  12. 12Billing with the supplier: The supply store bills the insurer electronically.
  13. 13Supplied.
  14. 14Refusal with notice of appeal rights: Refusal with reasons and notice of appeal rights.
  15. 15Refused.

After six weeks of illness the insurer pays sickness benefit

  1. 01Practice transmits the sick note (eAU): A warehouse worker has a slipped disc; after six weeks the employer stops paying wages.
  2. 02Sickness benefit case is opened: The electronic sick note becomes a sickness benefit case.
  3. 03Employer and insured provide data at the same time.
  4. 04Employer reports the pay: The employer reports the pay electronically.
  5. 05Insured returns questionnaire and account: The insured sends the questionnaire and bank details via the app.
  6. 06All data in.
  7. 07Calculate sickness benefit: The sickness benefit is calculated and granted.
  8. 08Payment run (daily 6 pm): The evening payment run transfers the first payment.
  9. 09Benefit continues, follow-up notes arrive: The illness continues; follow-up notes arrive electronically.
  10. 10Medical service assesses incapacity: The medical service assesses the incapacity.
  11. 11Case management: rehab and return to work: Case management plans rehab and a gradual return to work.
  12. 12Recovered.

A hospital bill is paid and reviewed

  1. 01Invoice arrives as a data record: A hospital sends ten bills as a data record, including a hip operation.
  2. 02Automatic check rules: Check rules compare diagnosis, procedure and length of stay.
  3. 03Hospital payment run (daily 2 pm): The payment run pays – flagged bills too are paid first, then reviewed.
  4. 04Paid.
  5. 05Billing review screens flagged cases: Billing review screens: is a review by the medical service worthwhile?
  6. 06Resolved.
  7. 07Medical service reviews the billing: The medical service reviews coding and length of stay.
  8. 08Apply the result: claim back or confirm: The result is applied: claim back or confirm.
  9. 09Corrected and offset.
  10. 10Confirmed.

An insured person objects to a refusal

  1. 01Objection arrives: An insured person objects to the refusal of an electric wheelchair.
  2. 02Department checks whether to remedy: The department checks again – often with new documents.
  3. 03Remedied.
  4. 04Medical service reassesses: The medical service reassesses, this time with a home visit.
  5. 05Objections office prepares the case: The objections office writes the brief for the committee.
  6. 06Objections committee meets (every four weeks): The self-government's objections committee decides.
  7. 07Objection decision: The objection decision is sent.
  8. 08Decided.
  9. 09Lawsuit at the social court: The insured sues at the social court.
  10. 10Decided by the court.

What you can change

Controls

  • Medical aid applications: After flu winters and hospital discharges many more applications arrive.
  • Medical aids casework: How many applications can be handled at once.
  • Automatic approval (electronic quote): If the electronic quote matches the contract, the system approves at once (shares are model assumptions).
  • Sickness benefit team: In a flu winter this is where money runs short – for the insured.
  • Review rate for hospital bills: More reviews recover money but tie up reviewers and the medical service.

Disruptions

  • Core system outage: Four hours without the member and benefits system: no notices, no calculations, advice on paper only.
  • Flu wave: For three weeks almost twice as many sickness benefit cases – and part of the staff is ill too.
  • Medical service overloaded: For a month all assessments take almost twice as long – the five-week deadline gets tight.
  • Data exchange disrupted: For three hours no sick notes, bills or quotes arrive.

What the model offers a health insurer

  • 01

    The insurer as a building

    Head office, customer centre, scanning centre, billing centre, data centre and city branch can be walked through and opened up, with 20 departments in their places.

  • 02

    Deadlines in motion

    The event simulation runs medical aids, sickness benefit, hospital bills and objections at the same time. Where applications wait, they visibly pile up.

  • 03

    Weigh automation against casework

    Five controls and four disruptions, from the electronic quote to a data exchange failure. When applications get stuck, a tip names the control that helps.

  • 04

    Diagrams for both boards

    14 diagrams in four groups are calculated live from the model – self-government included, as an organisation chart in space.

  • 05

    Ready to present anywhere

    In the browser and on large projections, plus a guided tour in eight steps for the first visit.

  • 06

    One of 36

    The insurer sits next to an insurance group, a hospital, a job centre and more, all in one overview. Created by an artist and developer rather than from a kit.

Basis and limits

Fictional health insurer · model based on researched structures of statutory health insurance · no statement about real insurers

1 case = 1 application, 1 sickness benefit case, 10 hospital bills or 1 objection · 1 figure ≈ 25 employees

All volumes, durations, rates and capacities are model assumptions, not values of a real insurer.

Deadlines under § 13 (3a) SGB V are simplified: measured is the decision within three weeks or the timely notice that the medical service reviews.

Documented: self-government with administrative board and objections committee, sickness benefit after six weeks of continued pay, payment before review of hospital bills, medical service as a separate body.

Public sources the model is based on:

  • SGB V § 13 Abs. 3a (Entscheidungsfristen)
  • SGB V § 33 (Hilfsmittel), § 127 (Verträge), § 139 (Hilfsmittelverzeichnis)
  • SGB V §§ 44–48 (Krankengeld)
  • SGB V §§ 275, 275c, 301 (Medizinischer Dienst, Krankenhausprüfung, Datenübermittlung)
  • SGB IV §§ 29–36a (Selbstverwaltung)
  • Sozialgerichtsgesetz §§ 78, 84, 85, 88
  • Entgeltfortzahlungsgesetz § 3
  • GKV-Spitzenverband: Kennzahlen der GKV
  • Bundesamt für Soziale Sicherung

Your health insurer as a model

Would you like to see your insurer with its own divisions, application backlogs and deadlines? Write to us or call; we will discuss which data are needed. Feel welcome to ask us for the password to the simulation.

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All data are fictional and the deadlines simplified. The model can be adapted to your insurer's real data and filled with what is not visible anywhere today – for example deadline compliance per month, or turnaround times of medical service assessments.