One of the branches that found a particularly warm response from the beneficiaries of GESS, the Health Insurance Organization (OAY) states in an announcement is that of Physiotherapists, with the System now allowing for a number of treatments (depending on the diagnosis) compensated by the Agency.
The Physiotherapy services joined the GESS during the implementation of the 2nd phase of the Health System, from December 1, 2020, together with the services of other health professionals.
How is the referral made and what applies to the treatments
The beneficiary of GESY who may need physiotherapy services has the opportunity to contact his personal physician, who will assess whether he needs to receive physiotherapy services or further evaluation by a Specialist Doctor.
All Personal Physicians and most Specialist Specialties have the ability to refer beneficiaries for physiotherapy services.
The beneficiaries, if they provide a referral, select the physiotherapist they want to visit from the list of physiotherapists who participate in GESS and make an appointment.
It is noted that GESS covers a specific maximum number of physiotherapy sessions per diagnosis, per beneficiary, per year. The beneficiary can receive information regarding the maximum number of visits covered by the System by the treating physician, who will refer him to the services of a physiotherapist, if deemed appropriate. For each physiotherapy session the beneficiary pays a supplement of ten euros.
At this stage, two types of referrals are issued, the short-term and the medium-term. A short-term referral is issued for 3 treatments and has a time limit of 6 months to execute. A mid-term referral is issued for 6 treatments, and also has a time limit of 6 months to execute.
The number of treatments that the GESS compensates, depending on the beneficiary's diagnosis, is listed in the tables of covered diagnoses that are posted on the GESS website. Each referral issued is valid for a single diagnosis.
The number of treatments per year and the exceptions
Adult patients are entitled to receive a maximum of 12 treatments per year, for diagnoses covering these services. For example, if a referral is issued regarding a diagnosis for which GESS reimburses up to 6 sessions and within the year a new referral is issued regarding a diagnosis for which GESS reimburses up to 9 sessions, in case the beneficiary has already received the 6, then only 3 can be executed within the same year.
In cases where the physiotherapist and the treating physician deem that a specific case needs more treatment, then they have the possibility to submit a request for exemption together, something that will be evaluated by the Organization.
This procedure is applied only in exceptional cases of serious health problems and provides detailed documentation of the incident by the applicants using a special form.
The maximum number of treatments that a beneficiary can receive under the GESS are calculated on the basis of a calendar year.
Issuance of referrals, individual cases
In cases where a patient submits a referral whose diagnosis (code) does not exist in the list of diagnoses for which GESS reimburses physiotherapy services, then the services offered will be charged outside GESS, according to the invoice of each provider.
In addition, in cases where the beneficiary does not have or does not submit a referral in force, then it is considered that these services are outside the framework of GESS. In this case, the physiotherapist has the opportunity to perform the visit with the appropriate charge, after first informing the beneficiary. The same applies in cases where the beneficiary has exhausted the maximum number of visits, as defined by the Agency.
The provision of home care services is not included in the service package agreed with the Agency. However, if the beneficiary's condition is such that he needs home care, it is up to the physiotherapist if he wishes to provide such services. In any case, one of the existing services included in the package of physiotherapy services should be used.
Finally, the physiotherapy services provided during the beneficiary's hospitalization are reimbursed in the context of the beneficiary's entire hospitalization and do not require any additional compensation on the part of the beneficiary.
Source: KYPE
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