Published by SA Media Holdings - September 2016
It is no secret that there is tension in the healthcare industry on multiple levels. At one end we have economic pressure on patients and their families driving medical contributions down. This downward trend impacts the other end of the market and drives pressure to craft cheaper Scheme Plan Options offering less and less value to ensure sustainable growth and profits.
In the middle of these two extremities lies the landscape of medical practices across multiple disciplines, hospitals and clinics as well as software and data switching systems, all under pressure to deliver more for less. This multi directional pressure has some strange effects on this ecosystem and the behavior of the role-players in it. It will ultimately impact how the industry will look in the future as the ecosystem is forced to move towards being more efficient and lean in order to survive.
The one thing that won’t change is the requirement for accurate data from end to end as this information impacts not only the administrative and financial workings of a practice, but ultimately the records that are used to make crucial decisions when it comes to reporting on and addressing practice profiling and the peer review system. We all know the saying “garbage in, garbage out”. This almost always refers to the source data that was entered into a system. If this source data is incorrect it will have a ripple effect throughout the decision making data trail.Take for example one of the tension areas between medical practices and medical schemes where medical practitioners are feeling victimized by the schemes as they come under sever scrutiny which quite frequently results in penalties, fines and charges. To this end, one has to look at the data that was originally captured at practice level to submit claims. This data has to be correct in terms of ICD10 and procedure codes and also needs to accurately reflect any consumables that were used and medication that was prescribed.
To save costs, practices often make sub-optimal decisions in terms of appropriate software, switching systems and more importantly, suitably qualified and trained staff. A fair portion of medical practitioners opt for bureaus, which come in many shapes and forms. Some are sophisticated well run operations that provide value for money and bring certain efficiencies to medical practitioners.
At the other end of the bureau spectrum is what may be viewed as “paper claim converters”, typically a team of people that are capturing claims as quickly as they can in a business process that in itself is already way behind the “Real Time” curve. Keep in mind that the medical practitioner is the original custodian and source of the medical information and should be the one determining the ICD and procedure code as well as the codes for consumables linked to the various procedures.
If this data has to pass through multiple parties and interpretation has to be done at each handover, the chances are that at some point, an error or multiple errors will be made. We know that most people more often than not will choose the path of least resistance and the same applies to work environments where staff are under extreme pressure to get through work. If an administrator or data capturer has difficulties in reading a doctors handwriting and or has trouble interpreting what should be claimed, logic says that they may well choose codes that they know will be immediately accepted by the medical aids, in this way avoiding the time consuming and often frustrating process of clarifying or looking up the correct codes for submission.
The critical question at this juncture is – was the claim constructed correctly?If claims and timelines are not accurately captured, the downstream impact on practice efficiency, profitability and profiling can be disastrous.Based on the logic of causality, where an action in one area results in a ripple effect downstream, often referred to as “cause and effect”, it is imperative that claims should be captured correctly, ideally in “real time”, in a system that takes the guesswork out of downstream activities. In a perfect world, the claim should be submitted to medical scheme administrators prior to the patient leaving the medical practice.
By doing this, it would mean that a system is in place for the medical practitioner to accurately capture the ICD10 and procedure codes as well as any consumables used, and in so doing remove any doubt and guesswork that could create errors down the line. This also gives the practice the opportunity to request payment for the “patient liable amounts” prior to the patient leaving the building. This not only reduces the risk of erroneous claims, but also financial risk of bad debt and short-circuits the down the line need to collect outstanding amounts – arguably the most unpleasant part of any practice administrators function.
Now imagine a scenario where a medical practitioner has passed on his files or claim forms to a third party that may not understand the importance of correctly loading the critical source data. If this person takes it upon themselves to capture claims in a way that makes their lives easier and reduces frustrating and time consuming follow up, they may well be ensuring that the practitioner gets paid sooner, but they may be missing the critical steps that are required to ensure the practitioner is getting paid correctly and the scheme is getting the correct data in terms of claims on behalf of their members.
Accurate data is critical for a multitude of reasons. It would be wise to ensure that the systems you use and the procedures you follow are adequate to deliver the correct data – anything that is incorrectly claimed, can be construed as FRAUD!!