Minimum Requirements for Coding & Tariff Determination of New Technology - Casper Venter Director HealthMan (Pty) Ltd

Transcription

1 Minimum Requirements for Coding & Tariff Determination of New Technology - Casper Venter Director HealthMan (Pty) Ltd Medical Devices and Health Technology Assessment: Resolving the Puzzle

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6 Market inquiry focus (draft) Hospitals Medical Schemes Administrators and Managed Care Organisations Specialists General Practitioners Market inquiry focus (revised) Medical devices and Pharmaceutical industries Integrity of the regulatory framework acknowledged and incorporated

7 Market inquiry focus on Specialists & GPs The How? of Tariff setting and the role of industry reference lists GPs as gatekeepers; referral processes and relationships with Hospitals and Specialists Hospitals; relationships with GPs and Specialists, incentives and access to operating facilities HPCSA Rules- promotional activities and employment of Doctors by Hospitals Alternative Reimbursement Models (ARMs)

8 Lack of an Authoritative Reference Source for new codes & queries Code Manipulations and billing malpractice exist and on the increase Certain procedures in the past were described by one or two codes with a few additional codes for the complicated case. Now routinely being used and more codes added. Guidelines established are not freely available, RPL does not exist, however many Schemes still use 2006 NHRPL, especially in Forensic Reviews Unilateral decision making process by Schemes and Providers Lack of transparency Not all providers support the structure in place Determination of RVU values Lacks transparency and outdated Review of existing RVU values- Top 300 review New technology/techniques Use of existing codes and adding others to make up fee Unnecessary motivations required No guidance on how to set new codes or RVUs Cannot set a Tariff!! Only a RVU, but no Crosswalk for RVUs

9 Let s look at some of the statistics that generate medical services invoices

10 Code Analysis: Percentage by Value Specialist Payments Data (Consulting & Surgical) Code Percentage (%) Consultations 29.73% Modifiers 7.67% Materials 3.31% Procedures & Equipment 59.29%

11 24 Codes comprise 50.34% 100 Codes comprise 74.92% 200 Codes comprise 85.15% 300 Codes comprise 90.26% 490 Codes comprise 95.01% Codes comprise %

12 Rank Code Type Code % Utilised /5 Psychotherapy Obstetrics Caesarean /9 Cataract ICU Multiple Organ Failure Ultrasound ICU Category Total Colonoscopy Cardiac Examination Obstetric Normal Delivery Multistage treadmill Arthroplasty: Debridement Joints Upper Gastro Endoscopy 0.83

13 Codes Discipline 1 25 Cardiology 2 4 Cardio Thoracic 3 17 ENT 4 30 Gynaecology 5 17 Ophthalmology 6 69 Neuro Surgery & Orthopaedics 7 8 Neurology 8 3 Psychiatry 9 52 Surgery Urology Pulmonology Consultations/ E & M Codes

14 Code Descriptor RVU Frequency Practices Amount 0201 Medicine & Materials - 2,490, Pelvic Sonar , Multi-stage Treadmill , Phako emulsification apparatus: Hire 3615 Routine Obstetric Ultrasound, weeks 3009 Basic Capital Equipment used in own rooms by Ophthalmologist 3617 Routine Obstetric Ultrasound, weeks , , , , ,229, ,385, ,250,328 77,852,738 51,526,278 51,276,268 40,340,935

15 Code Descriptor RVU Frequency Practices Amount 1019 ENT Endoscopy in Rooms 12 62, ,324, Pacemaker: Permanent: Dual Chamber 3201 Laser apparatus (Ophthalmic): Hire 230 2, ,893, , ,811, Vitrectomy apparatus: Hire 120 4, ,903, Ultrasound examination include whole abdomen 60 24, ,335, Ultrasound of joints 50 11, ,043,428

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17 Coding Application Process Submissions Stakeholders SAPPF/SAMA office Specialty Assoc. Publish New Codes Review & Prepare Documents Technical Committee Reviews Joint Coding Meetings Funding Industry

18 Descriptor Fee RVU CPT Code Ambulatory, Continuous Glucose Monitoring of interstitial tissue fluid via a minimum of 72 hours SA Code R Interpretation and report of Ambulatory, Continuous Glucose Monitoring R137 Or R Consultation Scheme Rate (RCF) R Procedure Scheme Rate (RCF) R

19 Diagnostic Equipment Cost Price R (Ex VAT) Prime Overdraft Rate 9.5% ROI 4.5% (above Prime) Ammortisation 5 years Maintenance 2% per year Insurance 1% per year Utilisation per Practice 40% Average minutes minutes Number of Sites in SA 150 Procedure Time 15 to 45 minutes Annual Utilisation procedures

20 Results (Ex VAT) Ammortization Costs R Equipment overhead rate per minute R Professional labour rate per minute R Mammography labour per minute R 3.43 Cost Based on Minutes R Imaging Scheme Rate R Relative Value Units?? 118 RVUs Previous RVUs 50 RVUs

21 CUSTODIAN SOUTH AFRICAN CLASSIFICATION FOR HEALTH INTERVENTIONS ( SACHI ) DIAGNOSTIC CODING PROCEDURAL CODING DRG S ICD - 10 ADVISORY COMMITTE EDITORIAL PANEL RELATIVITIES COMMITTEE COST COMMITTEE POLICY COMMITTEE DESCRIPTORS STANDARDS, STATISTICAL IMPACT CODING AND CLINICAL RULES TIME PRACTICE COST LIAISON, STATE LIAISON, OUTCOMES CODING CONSULTANT RESPONSIBILITY FINANCIAL CONSULTANT HEALTH TECHNOLOGY ASSESSMENT CODING CONSULTANT COMPLEXITY GEOGRAPHICAL FACTOR ACTUARIAL CONSULTANT SCARCE SKILLS

22 The Way Forward Maintenance of current coding structures lacks a governance structure Involve all Professions and Stakeholders South African Classification of Healthcare Interventions (SACHI) Take control of the governance process Maintain custody of coding structures within professional societies Urgency! Co established and MOI being drawn up

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