Health

1. [i] All patients who are discharged after admission to a hospital receive a discharge letter. This is standard practice for health professionals across the country.

[ii] The Department is compliant with the current ICD-10 Master Index Table [MIT] as per the National Standards on ICD-10 coding. Furthermore, no claims are submitted to medical schemes where ICD-10 codes are omitted or are not compliant with coding rules.

The following mitigating measures are in place to ensure complete and accurate ICD-10 coding:

• All users entrusted with coding of medical scheme related claims have received extensive training and have access to in-house refresher training as and when required. The users have access to electronic ICD-10 coding tables and, if required, to the hard copies of the coding manuals.

From a system control perspective, the MIT is loaded in the Department’s Health Information System [HIS], i.e., the patient clinical and billing system. Inherent rules are also built in to guide the user w.r.t. validity, sequencing, and completeness when selecting the appropriate ICD-10 codes.

A further final system control exists before the claims are electronically switched to the various medical schemes. Claims that do not meet the strict coding compliance are identified by the switching system and rejected.

The rejections for the last 3 years were 8% for Jan to Oct 2021 and 7% for both 2019 and 2020 calendar years.

The latter switching system is a real time online system which interfaces with the HIS system and thereby provides the health facility with the necessary access for the correction of the rejected cases. Control reports are monitored at facility and head office level to ensure the rejected codes are resolved timeously and resubmitted to the switching system for submission to the respective medical schemes.

Thus, only claims that are fully compliant with the ICD-10 rules are released to the medical schemes.

1. The Department’s patient registration and billing system, namely, Health Information System [HIS] has inherent controls to ensure that patients are correctly fee categorized and billed the appropriate tariffs.

There are various system attributes e.g. medical scheme funded, RAF funded or unfunded which determines the patient’s applicable fee category. This patient fee category for the various attributes is predetermined in the Billing Masterfile according the UPFS policy and is thus not selected directly by the user [which could lead to errors] but is rather determined through various pertinent information captured in the system.

System attributes for the unfunded patients includes amongst others, application of the means test, whether the service is a free statutory service, e.g., recipients of social grants, free maternity care, or children under 6 years. Again, the system determines the free category based on the relevant selection by the user, for example, the grant details or the patient’s date of birth must be captured before the system allocates the free patient status. There are various documents that the patient is expected to produce on registration, failing which, the patient will be assessed at the maximum tariffs.

It is also relevant to note that the bulk of health service is rendered at primary health care level where the treatment is rendered free to all users.