Made to Measure

Up until 2010 all medical aids except Discovery paid the same benefits, but since then they have all determined their own rates every year.  To get and capture the rates for all the codes for all the different disciplines, and all the different medical aids – not to mention all the different plans – would be an impossibly time consuming and expensive exercise.   Therefore we have structured the billing rates as described below.  This allows you the flexibility of a variety of functions that can help you to set your rates to suit your practice.

Discovery:  We hold the Discovery rate (DHR) for the current year in its own column.   For common disciplines without too many codes we are able to supply these rates to you by means of the Web import on your Tariff code screen.  Alternatively you can capture these rates manually.  For disciplines where we cannot supply the rate on our website, you can use the ‘Increase’ button to apply the % increase (5% in 2018) to all your codes (or for greater accuracy you can generate the rates from RCF and unit data – see below).  Everybody should check the prices before invoicing to ensure that they are not more than the published Discovery rate as this would cause the patient to be paid instead of the provider.

IOD: These rates are available from the dept of labour yearly in April. http://www.labour.gov.za/DOL/legislation/notices/medical-tariffs/medical-tariffs?searchterm=medical+tari

We will upload them for the common disciplines but others will need to apply the % increase announced.

Private:  Set your own rates.  You can use the ‘Copy’ , ‘Clear’, and ‘Increase’ buttons to help generate private rates.

Special Columns:  Columns that you have added to the tariff code screen that hold accurate rates for certain funds and that you maintain from year to year.  (see below)

All other Medaids:

These rates will be based on the 2010 rate which we hold in the MedAid2010 column.  Do not be alarmed that these rates look low and never change  – they are from 2010 so should stay at that low rate.   Then on every medical aid we hold a % that represents how much the rate has gone up since 2010.  Eg if Bonitas is billing MedAid2010 at 155% that means that when you invoice a Bonitas acct, the Medaid2010 rate will be increased by 55% on the invoice. Different Medaids will apply different %’s because their yearly increases since 2010 have not been the same.

For some Medaids the results will be inaccurate because of the way they have increased their rates.  GEMS is usually a problem as are the Medaids which have been taken over by Discovery and not yet on the DHR, because there are changes to the weightings on the codes.  For these funds you have 2 options:

• If it is important to be 100% correct with the rates, or you have many clients on the fund, then it is worth setting up a special column for just that fund.  Do this by using the ‘Columns’ button on the tariff code screen to add / assign the column to a particular Medaid eg GEMS.  Then on the MedicalAid screen change the billing information for that Medaid to use the new column at 100%.  Enter the published rates in the new column.
  
  
• Tweak the % on the MedAid so that it results in invoiced amounts that are slightly under the published rates to avoid being left with irritating amounts to write off.

Calculate as follows: 

•  SUBTRACT the 2010 Base Rate (R31.80) from the Actual Rate (R49.70)

•  DIVIDE this difference (R17.90) by the 2010 Base Rate (R31.80)

•  MULTIPLY by 100 - then ADD 100

Do this calculation on a selection of codes that you use often and then take one of the lowest % and put it into the billing% on the Medical aid.

Generate rates from RCF and unit:

This is the most accurate way to generate correct rates for different funds and different plans.  It requires that each code has its units (weighting) and CFAC (conversion factor) entered in the relevant columns.  We will have provided these for all disciplines except Dentistry which does not use them.  Then you can easily generate prices for all codes by entering just the RCF (Rand conversion factor) which is supplied by the medaids for all their plans. Eg  for Conversion factor of type  20 (CPU)  Discovery will supply a Rand value per unit for CPU of R12.809 (2017).  Use the increase button to do these calculations for you.  It will multiply the units by the rand value and generate the rates for all lines of type 20 (CPU). (See Helpfiles)

Exception Codes:

When the Medical Aid % is working well for most codes but there are a few that are too far out, then you can use an exception code to override the calculated value.  This is most often used by Doctors as the clinical procedures work well with the % increase but the consultations are set to fixed amounts by the funds.  (See Helpfiles)