SpesNews Volume 113
THE CERTIFICATE OF NEED (CON) INVALIDATED
The Constitutional Court declared the proclamation made by President Zuma regarding the requirement for a Certificate of Need, invalid. The deadline of 01 April 2015 (no pun intended regarding the date) for application for the certificate is no longer cause for concern.
The grounds for the invalidation are centred on the promulgation of the Act without the required regulations set in place – a situation making it impossible for the doctors to comply. This forced the President to apply to the Constitutional Court to declare the section invalid as he could not withdraw the proclamation.
Had the resolution been anything else, practicing doctors could have once again been faced with yet another frustrating scenario of having to proof that their services are required. This statement is made not even taking into consideration the acute shortage of medical practitioners in South Africa. Had the proclamation not been declared invalid, doctors practicing without a CON would have been guilty of a felony punishable by also imprisonment.
Allow me to rephrase: The Doctor would have been guilty of a felony for treating a patient who came to the doctor for medical management against a background where medical services are in demand while the doctor legally and ethically is compelled to treat the patient, especially in emergency situations.
While it is true that the distribution of medical services remain unbalanced at present and that various Acts does allow for the implementation of methods to address this scenario, somewhere in this entanglement of unfortunate events certain individual rights should remain intact. The way forward is almost impossible to predict – its outcome even less so. What has been proven to work best in these instances is a collaborative and consultative approach with all the stakeholders concerned.
I am reminded of a saying that is becoming more familiar:
If everything goes right, I save a life at scheme or private (if I am lucky) rate. If something goes wrong with that same life, its value suddenly becomes millions.
FORENSIC AUDITS – CODE 2493
In the light of increasing forensic audits currently being implemented, SpesNet would like to extrapolate on the following:
Diagnostic laparoscopy (excluding after-care)
ADD to open procedure where procedure was performed through a laparoscope (for anaesthetic refer to modifier 0027)
Where a purely diagnostic endoscopic procedure is performed, the use of the code 2493 is recommended.
Where a diagnostic procedure is performed (for example a diagnostic endoscopy for abdominal pain) and a therapeutic procedure accompanies the diagnostic procedure (appendicitis diagnosed and an appendectomy is performed), the code for the procedure is claimed for together with the code 1807. In this instance the use of 2493 cannot be recommended.
Currently medical schemes are reimbursing for the use of codes 2493 + the therapeutic procedure code and at a later stage via a forensic audit reclaim the value difference between the 2493 and the 1807.
As always, the SpesNet recommendation is non prescriptive and the decision on the use of a specific code entirely depends on the practice.
Remunerative Work Outside the Public Service (RWOPS)
GEMS is currently requesting confirmation from some practices that the medical specialist indeed is allowed to claim for the management of GEMS patients. This is where the medical specialist would also be employed in the public sector. In order for GEMS to consider reimbursing the specialist for the services rendered, the scheme is now requesting a copy of the application submitted to the employer for RWOPS permission for the current year. The applications are also valid only for a period of 12 months and it would require annual re-application. Documentation should be forwarded to firstname.lastname@example.org