Institutions: Medihelp & Medcodelink
Participants
- Medihelp, a South African open medical aid scheme that provides financial services prescribed by the Medical Schemes Act.
- Surgeons who are members of Surgicom, an organisational body for general surgeons in South Africa.
- Surgicom members:
- Fair and equitable remuneration for the professional services they provide.
- Medihelp:
- Furtherance of appropriate medical coding.
- Effective administration of claims for medical services.
- Optimisation of benefits for suppliers of medical services and medical scheme members.
- Collection of meaningful electronic patient data with a view to effective disease management and planning.
- The prevailing coding system currently used in SA for professional services provided by medical practitioners is replaced with the Current Procedural Terminology [CPT® (registered)] system only © (Copyright) 2004 American Medical Association (AMA), customised for South Africa as per Complete CPT® for South Africa (CCSA), published by the South African Medical Association (SAMA).
- A standardised software database that contains essential links between, inter alia, CPT® codes for professional medical services and ICD-10 codes (International Statistical Classification of Diseases and Related Health Problems, Tenth Revision) is employed for automated verification of the diagnosis codes provided with the relevant procedure codes.
- In accordance with the specifications for implementation of CPT® in SA by SAMA, the coding rules embodied in the CPT® coding system and Medicare Resourced Based Relative Value Scale (RBRVS), are applied in the claims validation process.
- Management of remuneration and monitoring of billing profiles are conducted through regular negotiations between the two participants.
- Appropriate validation and payment of claims
- Mutual acceptance of standarised coding rules and conventions.
- Improvement in the development of coding skills within the ranks of both participants, particularly as a result of continued research and communication on coding issues.
- Collection of statistically valid electronic health data by the funder.
- Significant improvement in patient/doctor/funder relationship.
- Ability to collate and share into the benefit of the whole industry
- Utilisation of scientifically sound and standardised coding schemas and tools and available technology in the validation and administration process of claims for professional medical services, contribute significantly towards
- Enablement of funders of medical services to comply with the full scope of legal requirements.
- Financial savings for the funder which can be passed on to members;
- Fair and equitable remuneration for the providers of services.