• 13 Apr 2016

    SpesNews Volume 130

    Discovery Health Day Hospital Remuneration

    Discovery Health is offering enhanced remuneration for selected surgeries performed in a day hospital facility. This is being offered to enable increased efficiency alongside the enhanced professional reimbursement in a sustainable manner.

     The Day Surgery Remuneration Enhancement offer is available to any willing surgeon, currently on the Discovery Health Direct Payment Arrangement. Participating surgeons will benefit from a significant increase in their chosen DPA rate for all procedures performed in a day surgery facility (77 facility) as indicated in the table below:

    DPA

    Member Plan Type    

    Acute Hospital Rate*    

    Day Surgery Rate*#

    Classic Direct    

    Classic

    217%

    230%

    Essential

    Coastal

    100%

    200%

    Premier A

    Essential

    Classic

    Coastal

    137%

    167%

    Premier B

    Essential

    Classic

    Coastal

    147%

    177%

    Executive

    Executive

    300%

    300%

    * Expressed as a % of the DH rate

    # No balance billing in access of these rates

    This is applicable to all procedures performed in a day surgery facility, excluding ophthalmology, maxillofacial and oral surgery, dentistry, GIT endoscopies, consultations and procedures typically performed in the rooms.

    Discovery Health is currently at various stages of development regarding these procedures to explore the feasibility of initiative specific payment arrangement enhancements.

    Participation Criteria:

    1. Participation in one of the Discovery Health Direct Payment Arrangements (DPAs)
    2. No balance billing of the members

    Access to the Rates:

    1. The rates are available at www.discovery.co.za
    2. The normal pre-authorisation process should be followed by calling 0860 998877 or electronically on www.discovery.co.za / Your hospital admission
    3. Submit the enhanced rate with the place of service indicator:

    24

    Day Clinic / Hospital

    Please Note that there are certain codes for procedures that would typically always be performed in rooms that are not included for reimbursement. The arrangement applies to all Discovery Health medical scheme options excluding KeyCare and all in-house schemes participating in the DPAs. Priority and Delta plan deductibles will remain in place where applicable. Please contact Discovery Health Medical Scheme on healthpartners@discovery.co.za for further information.

    Competition Commission 

    The Competition Commission enquiry into private healthcare is currently underway and the stakeholders face a mammoth task of combing through the roughly almost 15 000 pages that have been submitted. With all the major players all geared towards presenting their findings and recommendations, this was never going to be an easy task. It was however, always going to be an important task. With its aim to determine whether the private healthcare industry operated in a collusive or restrictive manner to remove factors that would inhibit or prevent access to healthcare, its findings could no doubt be implemented to lay the foundation for the long awaited NHI.

    Some stakeholders have been unable to make any submissions to due issues around confidentiality but former chief justice Sandile Ngcobo who is currently holding office as the chairperson of the panel, indicated that delays at this stage could significantly impact the November final report deadline.

    While it would appear as if there is no contention with regard to the cost of the services rendered by the private healthcare industry, nor the fact that the inflation in the private healthcare sector overshadowed that of CPI, submissions is expected to provide the underlying rationale for these prices as well as the possible justification for the same.

    The most obvious loci of power could probably be contributed to the medical schemes, private hospital groups and the healthcare specialists, but other factors should and must be considered.

    These include the under- or overregulation not only within the healthcare industry, but also the industries that latches onto the healthcare industry. A few examples of these would be the Broker community, the (non-medical scheme) insurance companies and the legal fraternity.

    Some of these are addressed in the presentation of Dr Aaron Motsoaledi (obtainable here) while a significant portion remains unaddressed. Medico-legal indemnity insurance costs have actually become astronomical and in some cases, practice doors have been shut due to unsustainability. Any solution would not be a simple one and unless the whole picture in all its relations and dependencies are completely considered, singular isolated interventions could spell disaster. Whatever the outcome, the enquiry allows for key role players to once again convene and extrapolate on problems practices are faced with on a daily basis – this is always a good approach.

     

    Bonitas Standard Option

     

    SpesNet received confirmation that the technical administrative errors that have hindered Bonitas Standard claims, have been resolved and practices affected are advised that normal claim submission procedures can be resumed. Practices are also encouraged to be vigilant in their reconciliation of these claims and if they experience any problems or have queries, it can be directed to the Medscheme Callcentre.

     

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.

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

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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.