• 31 Jul 2015

    SpesNews Volume 120

     PMB AT COST AT 2006 RPL + CPIX

    The Medical Schemes Act 131 of 1998 and regulations to the Act have always been a very sensitive area for most practices, patients and medical schemes. The often debated regulation 8 states that medical schemes are required to reimburse for the treatment of Prescribed Minimum Benefit (PMB) conditions at cost. To manage the risk of reimbursing PMBs at cost, other regulations allow a medical scheme to apply treatment protocols, formularies and Designated Service Provider (DSP) networks. Schemes can also employ underwriting (exclusions, waiting periods and late joiner penalties) to discourage anti-selection against the scheme and/or manage some of the financial risk new members could present to the scheme. The "treatment at cost" issue however remained the thorn in the side of many schemes and administrators. The fact remains that healthcare expenditure has escalated to such a level that an enquiry was initiated by the Competition Commissioner (CC). Unfortunately, the perception has been created that the medical specialists are the main culprits responsible for the escalation in the healthcare costs. The new amendments proposed aim to address this "specialist cost" problem by limiting the responsibility of a scheme to reimburse for PMB conditions at 2006 NHRPL tariffs + annual inflation. If the new amendments are approved in its current form, not only will specialists be operating in a rather over-regulated private healthcare industry - reimbursement will also be severely adversely affected. undefined

    Please be reminded of the number of Acts already impacting directly on the operations and administrative time in a practice. Kindly refer to the diagram on the left illustrating the impact of some of the more prominent ones. In fairness, all of these Acts have good intensions and should be supported, however, should the amendments be accepted, a significant co-payment from the patients can be expected as a result. Patients can thus expect to be confronted by a restricted choice in providers, limited treatment options (directly linked to their ability to bring about a co-payment) as well as an additional financial burden. How the proposed amendments to the act will offer the patients protection of their constitutional rights as well protection against catastrophic events (one of the objectives of the PMB legislation) remains unclear. Another point of concern is on what basis the cost of the PMBs was calculated to be equivalent to the 2006 NHRPL tariff with an annual inflation-linked increase. For a link to the amendments please click HERE. Please forwarded comments to: The Director-General: Health, Private Bag X828, Pretoria, 0001 (attention: Director: Public Entities Governance and Management.

     REMINDER OF THE PROMOTION OF ACCESS TO INFORMATION MANUAL (PAIA MANUAL)

    SpesNet would like to remind practices that the deadline for the Section 51 Manual (Promotion of Access to Information Act – PAIA) is 15 December 2015 - the template can be obtained by clicking HERE. The template has clarified the question around the expected contents of the manual to a huge extent and SpesNet would like to urge practices to (even if you are considering outsourcing it) download and have it on hand for use or comparisons.

     

    Please be reminded of the number of Acts already impacting directly on the operations and administrative time in a practice. Kindly refer to the diagram on the left illustrating the impact of some of the more prominent ones. In fairness, all of these Acts have good intensions and should be supported, however, should the amendments be accepted, a significant co-payment from the patients can be expected as a result. Patients can thus expect to be confronted by a restricted choice in providers, limited treatment options (directly linked to their ability to bring about a co-payment) as well as an additional financial burden. How the proposed amendments to the act will offer the patients protection of their constitutional rights as well protection against catastrophic events (one of the objectives of the PMB legislation) remains unclear. Another point of concern is on what basis the cost of the PMBs was calculated to be equivalent to the 2006 NHRPL tariff with an annual inflation-linked increase. For a link to the amendments please click HERE. Please forwarded comments to: The Director-General: Health, Private Bag X828, Pretoria, 0001 (attention: Director: Public Entities Governance and Management

    REMINDER OF THE PROMOTION OF ACCESS TO INFORMATION MANUAL (PAIA MANUAL)

    SpesNet would like to remind practices that the deadline for the Section 51 Manual (Promotion of Access to Information Act – PAIA) is 15 December 2015 - the template can be obtained by clicking HERE. The template has clarified the question around the expected contents of the manual to a huge extent and SpesNet would like to urge practices to (even if you are considering outsourcing it) download and have it on hand for use or comparisons.

    ARE YOUR PRACTICE MANAGEMENT PROCESSES OPTIMALLY ALIGNED TO ENSURE MAXIMUM INCOME?

    In this SpesNews we discuss the 2nd key factor to consider, for reaching optimal practice income:

    Business positioning.

    It is important that the Healthcare Practitioner has a good understanding of the following:

     The importance of a good Practice Management Application (PMA)/System that will improve active practice management, streamline workflow and optimise income

    Does your Practice Management Application:

     Highlight income related risks associated with the type of patient you are consulting?

     Automatically align the invoice with your practice billing policy, compared to the insured value of the patient’s funder plan option?

     Apply all Rules and Tariffs specifically aligned to the type of patient?

     Save HR time to ensure practice staff can focus on the crucial part of practice management, following your money?

     Advantages of Point of Sale (POS)/Credit Card Terminal to minimise risk associated with the management of cash in practice. Your POS terminal of choice should preferably be integrated with your PMA to minimise the potential risk of fraud.

     Importance of the Practice Bank registration details at ALL Schemes

     Evaluation of your Billing Policies for your practice to align with the demographics of the practice/area

     Evaluation of possible Payment Arrangements/Contracts with Medical Schemes according to the practice patient profiles

     The Tax benefits and implications of writing off bad debt or not

     Identification of PMA Reports, to assist with managing the practice at a glance, on regular basis, in order to minimise risk within the practice

     Monitoring your AGE analysis of your practice closely

     The importance of having HR policies and procedures in place (Contracts etc.)

Our partners

EthiQal is a comprehensive Medical Indemnity solution developed for South African Medical Practitioners by Constantia Insurance Company Limited. Local risk assessment based on South African private sector settlements only. Specialty focused support and inputs to practice management. Provision of Occurrence and Claims Made insurance cover. Insurance contracts which are enforceable in terms of South African law and Regulations.

DUXAH, The DUX Academy of Healthcare, evolved from within SpesNet, a company established by medical specialists to assist medical specialists and recently qualified registrars to negotiate the fraught business of private practice.

Optimising practice income! Get all the power, functionality, and flexibility your Specialist practice needs, plus the convenience of the Web.

ProfNet provides business management tools and practice support to maximise the income and efficiencies of private practice in the South African Allied Healthcare environment.

Evolve Medical is a leading provider of customised integrated software solutions.

When Discovery was established as a small specialist health insurer two decades ago, we made a clear and profound promise: to make people healthier. Making people healthier and enhancing and protecting their lives has evolved into our core purpose.