family practitioner network guide 2019docweb.co.za/practice-management/tariffs/2019... ·...

FAMILY PRACTITIONER NETWORK GUIDE 2019

INTRODUCTION

1. FAMILY PRACTITIONER NETWORK FEES

2. SPECIALIST NETWORK & SPECIALIST REFERRAL

3. CHRONIC AND ACUTE MEDICINE

4. VALUE-ADD PROGRAMMES/SERVICES

5. TOOLS TO HELP NETWORK FPS

6. HEALTHCARE FORENSICS

7. CONTACT DETAILS

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Dear Family Practitioner

Fragmented healthcare has in the past resulted in inefficient, costly treatment for our beneficiaries. That is why we have introduced the concept of care co-ordination, as we believe that this not only improves the quality of healthcare for our beneficiaries, but also lowers overall health expenditure.

As you are one of our Network FPs, we would like to thank you for the valuable services that you render to our beneficiaries. We would also like to make your task as easy as possible, which is why we have put together this guide. It aims to provide you with all the information you need to treat our beneficiaries effectively, including an overview of our Scheme’s value-add programmes and how these can complement your services to our beneficiaries.

Also note that there will be a 5.0% increase in the Nedgroup Medical Aid Scheme’s FP tariff rates with effect from 1 January 2019.

If you have any questions, please call the Healthcare Provider Contact Centre on 0861 112 666.

We look forward to partnering with you in 2019!

Julia le RouxPrincipal Officer

Nedgroup Medical Aid Scheme FP Guide | BACK TO INDEX

INTRODUCTION

The Nedgroup Medical Aid Scheme FP Network reimbursement model for 2019 will include an enhanced fee, in accordance with the practice’s REPI² category score as indicated in the table below, and will see a 5.0% increase in rates from 1 January 2019.

FP Consultation Rates (0190-0192) 2019Enhanced FeesAutomatically added when consult is processed

Nedgroup Medical Aid Scheme Rate R384.50 R42.40 (REPI2 Cat 1)

The enhanced fee will automatically be added when the practice is reimbursed for consultations.

It is important that FPs adhere to their contract requirement to bill the Nedgroup Medical Aid Scheme Rate, so that our beneficiaries are not faced with unexpected co-payments.


1. FAMILY PRACTITIONER NETWORK FEES

There is a growing trend of fragmented care, where a number of our beneficiaries are receiving duplicate treatment from multiple doctors and providers. This leads to poor patient experience and unsatisfactory outcomes in providing safe, appropriate and effective care.

We would like to remind FPs that there is a Nedgroup Specialist Network of doctors that will assist beneficiaries in minimising out-of-pocket expenses. From 1 January 2019, Nedgroup Medical Aid Scheme beneficiaries (with the exception of the Platinum Plan members) must consult their Network FP BEFORE making a specialist appointment in order for the FP to ensure that the patient is referred to the appropriate specialist. Should a beneficiary (except for those on the Platinum Plan) voluntarily be admitted to hospital by a non-network FP or non-network specialist, a R2 500 co-payment will be applied on admission to the hospital.

HOW TO OBTAIN A SPECIALIST REFERRAL• For all other options, please contact the Healthcare Provider Contact Centre

on 0861 112 666 and use the interactive voice recognition (IVR) function to obtain a referral number. You will need to have the following information ready:

– Your practice number, e.g. 1234567

– Your patient’s membership number, e.g. 00000000001

– Your patient’s beneficiary number, e.g. 00

– Your patient’s date of birth in the format DDMMYYYY, e.g. 31121954

– The practice type, e.g. 18 for a physician

– The number of months that you want the patient to visit the Specialist between 1 and 6, e.g. 3. A referral number will automatically be created for the member on the system, from the date that you created the referral and adding the number of months you have chosen to create an end date for the referral.

• Specialist Referral can also be done via the web:

– Visit www.medscheme.com > login as a provider > click on Specialist Referral (and complete all required information).

The network Specialists have all agreed to bill the Nedgroup Scheme rate; therefore, your patient will not incur a co-payment when consulting with these doctors.

PLEASE NOTE:• The Nedgroup network specialist is the Designated Service Provider (DSP)

for PMBs.

• To find out whether the specialist you are referring the patient to is on the network, you can contact the Provider Call Centre on 0861 112 666.

• Should you require to refer a patient to an orthopaedic surgeon (for hip or knee surgery), please first read the section on ICPS and JointCare.


2. SPECIALIST NETWORK & SPECIALIST REFERRAL

Please find important information below regarding chronic and acute medication for Nedgroup Medical Aid Scheme beneficiaries:.

CHRONIC MEDICATION BENEFIT RULES

How to apply for chronic medicine

• Biologicals: Please call the Nedgroup Contact Centre on 0861 100 220 or email [email protected].

• Non-biologicals: Please call Scriptpharm on 011 100 7557 or email [email protected].

Changes or updates • Changes or updates to biological chronic medication are done telephonically by contacting the Nedgroup Provider Contact Centre on 0861 100 220.

• Changes or updates to non-biological chronic medication are done telephonically by contacting Scriptpharm on 011 100 7557.

Co-payments Co-payments can be avoided by:

• Prescribing in-formulary drugs, or

• Asking the pharmacist to substitute expensive medicines with a generic equivalent .

Designated Service Providers (DSP)

• Biologicals: Pharmacy Direct is the DSP for all non-oncology biological medicine for Nedgroup beneficiaries. Please contact Pharmacy Direct on [email protected] or call Pharmacy Direct on the share call number 0860 027 800. Scriptpharm is the DSP for all oncology biological medicine for Nedgroup beneficiaries. Please contact Scriptpharm on 011 100 7557 or email [email protected].

• Non-biologicals: Pharmacy Direct has been appointed as the DSP for beneficiaries on the Hospital Plan. If a beneficiary obtains PMB medication from any other pharmacy, there will be a 25% co-payment. Please contact Pharmacy Direct on [email protected] or call Pharmacy Direct on the share call number 0860 027 800.

For all other options (Platinum, Comprehensive, Traditional and Savings Plans), Scriptpharm is appointed as the DSP for Chronic Medicine. If a beneficiary obtains PMB medication from any other pharmacy, there will be a 25% co-payment. Please Call Scriptpharm on 011 100 7557 or email [email protected].


3. CHRONIC AND ACUTE MEDICINE

The following programmes/services have been put in place to enhance the Nedgroup Medical Aid Scheme’s offering to beneficiaries and to ensure quality care at an affordable price. As FP, you can encourage our beneficiaries to make use of these programmes and services, where appropriate.

IMPROVED CLINICAL PATHWAY SERVICES (ICPS) & JOINTCARE

Nedgroup Medical Aid Scheme has partnered with ICPS and JointCare, who are a group of orthopaedic surgeons who specialise in performing hip and knee replacements according to standardised clinical care pathways to ensure that the quality of the hip and/or knee replacement is of the highest standard and to ensure the best health outcomes.

ICPS and JointCare are the designated service providers for Nedgroup Medical Aid Scheme beneficiaries for hip and knee replacement surgery. A R10 000 co-payment will apply for the use of a non-DSP for hip & knee replacement surgery.

ICPS and JointCare will ensure payment in full for the procedure, which will include the following:

• All hospital costs

• Surgeons and anaesthetist fees

• Prosthesis (subject to prosthesis benefit)

• Physiotherapist (pre-, intra- and post-operative)

If you have a patient who requires a hip and knee replacement, please call the Provider Contact Centre on 0861 112 666 for details of ICPS or JointCare orthopaedic surgeons close to the beneficiary.


4. VALUE-ADD PROGRAMMES/SERVICES

BACK AND NECK REHABILITATION PROGRAMME

The goal of the Back and Neck Rehabilitation Programme is to reduce the need for unnecessary surgery caused by chronic back and neck pain and to restore normal function. The Back and Neck Rehabilitation Programme will, for most patients, decrease pain, reduce stiffness and improve mobility.

All our Scheme Plans offer access to this programme. Beneficiaries who are eligible for the programme are proactively identified by the Scheme’s beneficiary risk management team. Eligible beneficiaries can also be identified by their FP, or they can self-refer.

The cost of the programme is covered by the Back and Neck Rehabilitation Benefit. Please note that this excludes the cost of any other investigations or medication prescribed by a physiotherapist or medical practitioner, in which case acute benefits and Scheme rules will apply. For beneficiaries who elect not to first use the conservative treatment offered by the Back and Neck Rehabilitation programme before back and neck surgery is performed, , surgery will be declined.

MENTAL HEALTH PROGRAMME

Patient activation and empowerment is becoming an important focus area in the management of chronic diseases. However, this may be a particularly difficult achievement in the patient with a mental disorder. In recognition of this, our Scheme offers a Mental Health Programme that employs innovative solutions for empowerment, and leverages off social, family and workplace support.

Benefits of the programme, compared to usual care, are as follows:

• Greater reduction in mental health symptoms

• Greater rates of care for mental health

• Improvement in quality of life

• Less functional impairment

• Better patient satisfaction

• Better provider satisfaction

• Significant benefits in terms of absenteeism reduction

The Mental Health Programme follows an internationally successful model of integrating mental health care into the primary care setting, through effective collaboration between family practitioners, specialists and auxiliary caregivers, and the introduction of a Care Manager to help co-ordinate the process.

Should you wish to enrol your patient in the Back and Neck Rehabilitation Programme, please call the Nedgroup Medical Aid Scheme Call Centre on 0860 100 080 to determine whether your patient qualifies to be enrolled on this programme.

Should you require more information about the Mental Health Programme, or wish to confirm whether your patient meets the criteria of our Mental Health Programme, please call 0860 106 155 and follow the prompts to select the Mental Health Programme, or email [email protected].


VALUE-ADD PROGRAMMES/SERVICES CONTINUED

INDEPENDENT CLINICAL ONCOLOGY NETWORK (ICON)

Nedgroup Medical Aid Scheme has partnered with ICON as its designated service provider for Prescribed Minimum Benefits (PMBs) and as their preferred provider for non-PMBs. ICON is a network of oncology specialists utilising standardised protocols to ensure that our cancer patients are appropriately cared for. ICON offers a network of oncologists who have agreed to use the clinical protocols approved by the Scheme and who will bill at the agreed rate, thereby ensuring that beneficiaries will not incur co-payments.

Where relevant, please refer Nedgroup Medical Aid Scheme beneficiaries to an oncologist within the ICON network, to ensure that they do not incur any potential co-payments. You can visit the ICON website at www.cancernet.co.za or call the Nedgroup Provider Contact Centre on 0861 112 666, or ICON SA on 021 944 3750, to find a close-by oncologist on the ICON network.

Please assist Nedgroup beneficiaries (excl. Hospital Plan) who want to participate in this programme by visiting www.gosmokefree.co.za to find out more and to locate your nearest pharmacy who can assist the beneficiary. Alternatively please call 0860 100 080.

VALUE-ADD PROGRAMMES/SERVICES CONTINUED

NEDGROUP GOSMOKEFREE PROGRAMME

Nedgroup offers all beneficiaries (excl. Hospital Plan) the opportunity and support to stop smoking. This is done via the GoSmokeFree Programme.

The benefits of stopping smoking are almost immediate, but stopping smoking is not easy, as nicotine is highly addictive and smoking is associated with social activities such as drinking or eating and psychological factors such as work pressure, anxiety and body weight concerns.

The GoSmokeFree Stop Smoking Programme is available at various pharmacies throughout South Africa using a trained Nursing Sister or Pharmacist, so access to the programme is easy.


ELECTRONIC MEDICAL RECORDThe Electronic Medical Record (EMR) is a digital version of a patient’s paper-based chart and aims to make it easier to share our beneficiaries’ clinical and demographic information with FPs who are on the Nedgroup Medical Aid Scheme FP Network.

The Independent Practice Association (IPA) Forum has provided their input with regard to the EMR.

The EMR provides FPs with the following administrative and clinical benefits:

ADMINISTRATIVE BENEFITS CLINICAL BENEFITS

• Decreased paperwork

• Decreased storage cost

• More efficient billing

• Recording of clinical notes

• Reviewing and setting up appointments for the patient

• Tracking of patient compliance

• Access to the patient’s medical history

• Electronic prescription of medication

• Access to up-to-date patient information, including clinical notes and results

• More effective diagnosis of patients

• Reduction of medical errors

• Reduction of duplication of care

• Provision of high quality care

The EMR was rolled out to a pilot group of doctors during 2017, to allow us to make further enhancements, based on feedback from the pilot group. In future, the EMR will be made available to more healthcare professionals. We will keep you informed on the progress of this exciting initiative.

CARE PATHWAYSEnsuring good clinical outcomes for our beneficiaries is a top priority for Nedgroup Medical Aid Scheme. Equally important is equipping doctors with the tools needed to achieve this. In consultation with experts in each chronic

disease field, practising FPs and scheme representatives, a process has been started to develop Integrated Care Pathways for the major chronic conditions. The goal of this collaborative effort is to develop care pathways that take into account clinical and financial implications, while at the same time being aligned to beneficiary benefits and a primary healthcare approach.

Going forward, care pathways will be shared with healthcare professionals and will also be incorporated into the EMR.

To date, a hypertension care pathway and a diabetes mellitus care pathway have been developed and can be accessed by visiting the Medscheme website at www.medscheme.com > Communication library > Communication > General Communication. Below is an extract of the hypertension care pathway that has been developed.

Add third drug / optimise doses of drugs

BP 140-159 / 90-99 mmHg with <3 risk fators, no TOD or

complications

BP 140-159 / 90-99 mmHg with <3 risk fators, no TOD or

complications

BP > 160 / 100 mmHg*

Lifestyle modification for

3-6 months

Commence monotherapy,

review in 4-6 weeks

Commensce 2 drugs preferably in fixed drug combination, review in 4-6 weeks

Not at goal Not at goal Not at goal


5. TOOLS TO HELP NETWORK FPs

Nedgroup Medical Aid Scheme uses world-class analytical software, Insurance Fraud Manager (IFM) developed by FICO, which employs advanced mathematical techniques to detect suspicious and abnormal claiming patterns. This ensures that our beneficiaries receive the best and appropriate patient care at all times, whilst minimising the financial impact of fraud, waste and abuse.

The claiming process for all healthcare professionals remains as is. Please continue to submit all claims as per the existing process. Valid claims will be assessed and paid. The claims data will then be reviewed to identify abnormal claiming patterns. If claims are found to be inappropriate, the relevant healthcare professional will be consulted to address the findings. Corrective measures will then be discussed and agreed upon to address the irregular claiming behaviour.

Fraud, waste and abuse will continue to be addressed in a fair and transparent manner, which includes taking into account best practice and clinical necessity, where relevant.

A healthy claims audit and forensic capability enables us to strengthen our ties with all healthcare professional bodies and ensures that we continue to work towards achieving our goal for holistic patient-centric and affordable care at all times.

For any fraud-related queries, please contact the fraud hotline on 0800 112 811 or email [email protected].


6. HEALTHCARE FORENSICS

SERVICE PURPOSE TELEPHONE EMAIL ADDRESS FOR QUERIES

Healthcare Professional Contact Centre (IVR) including Website Assistance / Nedgroup Medical Aid Scheme Provider Contact Centre

General queries related to Nedgroup Medical Aid Scheme

0861 112 666 [email protected]

Chronic Medicine Management (biologicals)

Chronic submissions and queries


Scriptpharm: Chronic Medicine Management (non-biologicals)

Chronic submissions and queries


Disease ManagementDisease management updates


Fraud Hotline Fraud-related matters 0800 112 811 [email protected]

Hospital Pre-AuthorisationAll hospital pre-authorisations for non-emergency events


Submission of claimsSubmissions of claims for Nedgroup Medical Aid Scheme beneficiaries


Queries of claims

Queries relating to a claim for a Nedgroup Medical Aid Scheme beneficiary


Oncology Services Oncology-related queries 0861 100 220 [email protected]

Ambulatory PMB Ambulatory PMB queries 0861 100 220 [email protected]

Aid for AidsAid for Aids Management



7. CONTACT DETAILS

family practitioner network guide 2019docweb.co.za/practice-management/tariffs/2019... ·...

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