WCA or IOD: Billing And Tariff Strategies

WCA Claims Billing Strategies: An Introduction

 

In line with previous WCA Claims articles in this ‘billing/tariff strategy’ section
we highlight the process of billing and discuss the current problems
in the South African context. Workman’s compensation claims are
amongst the most notorious and problematic accounts for timely
remuneration. Most health care service providers have resorted to employing
professional agencies to collect funds on their behalf at an enormous
cost burden to their practices.

 

Below is the normal sequence for compiling Workman’s Compensation Act accounts or WCA Claims:

Required documentation


Workman’s compensation claims should consist of the following documentation:

  1. A computer generated account with relevant practice number, relevant procedure coding and applicable ICD 10 codes preferably per visit.
  2. A copy of the W.CL 1 which is also known as the injury report.
  3. A copy of the first medical report W.CL 4.
  4. A copy of every W.CL5 report done by the referring doctor as
  5. follow up reports, and
  6. A copy of the identity document of the patient receiving care.

For wound care, additional documentation that can facilitate account
payments will be:

  1. The referral note from the surgeon requesting the service.
  2. Copy of the wound assessment done on first visit.
  3. Motivation letter similar to an authorization request letter used for medical schemes
  4. Follow-up reports on wound progress W.CL5.

The above routine is well accepted and adopted by service providers to fulfill their obligations for remuneration. It is costly, time consuming and laborious. However, the difficulties often only begin after this process has been meticulously completed.

Delays in payment to WCA Claims are the most common problem without any valid reason provided. Moreover, every few months additional changes are often made unilaterally without discussion, once again affecting past WCA Claims.

Consider the following scenario: If a patient has undergone surgery, complications arise and he/she is referred to a wound care specialist for further management. WCA officials have misinterpreted their own ruling and have decided that any treatment during this time by the wound care practitioner does not warrant a consultation fee or an application of dressing fee as the four month period after surgery should be covered by the original surgery as per the WCA Claims.

Included below are definitions of the various rules that demonstrate clearly that this practice refers to routine after care, practiced by the original surgeon, and not to complications or specialised treatment that is needed by a new practitioner. However, as seen in the examples below, the ruling has been misused and the wound care practitioner is unjustly uncompensated for work performed.

Definitions according to the Government Gazette 1 June 2005 Vol 480 No 27632 Notice 866 of 2005: Compensation for Occupational Injuries and Diseased Act (Act no 130 of 1993)

A. Consultations: New patients Page 11
a. Consultations: refers to a clinical situation where a medical practitioner personally elicits a patient’s medical history, performs an appropriate clinical examination and, if indicated, administers treatment, prescribes or assists with advice. These services must be face to face with the patient and exclude the time spent doing special investigations which receive additional remuneration.
b. A Subsequent visit refers to a voluntary scheduled visit performed within four (4) months after the first visit. It may imply taking down of medical history and/or a clinical examination and/or prescribing or administering of treatment and/or counselling

G. Post-operative care: Page 12

a. Unless otherwise stated the fee in respect of an operation or procedure shall include normal after-care for the period of FOUR MONTHS (after care is excluded from pure diagnostic
procedures during which no therapeutic procedures were performed).
b. If normal after-care is delegated to any other registered health professional and not completed by the surgeon, it shall be his/her own responsibility to arrange for this to be done.

Wound Healing Southern Africa 2009;2(1):31-32
32
Practice Management: Billing/tariff strategies
Wound Healing Southern Africa 2009 Volume 2 No 1
L. Procedures performed at time of visits: Page 13
If a procedure is performed at the time of the consultation/ visit, the fee for the visit PLUS the fee for the procedure is charged.
O. Costly or prolonged medical services or procedures: Page 14
c. In the case of costly or prolonged medical services or procedures the medical practitioner shall first ascertain in writing from the Commissioner for what account the Commissioner will accept responsibility in respect of such treatment.

Examples of codes that were rejected at Wound Care facilities and found on remittance advices from the Workman’s Compensation Fund iro of WCA Claims in the past few weeks:
B J D——: Item 88001 (first consultation) and 88041 (follow up consultations) were not paid, because there was a procedure done, therefore for four months no consultations can be paid.
F T MQ—-: Item 88041X17 (follow up consultations) were not paid, as there was a procedure done and therefore for four months after procedure was done no consultations payable.
T I N——: Item 88001 (first consultation) and 88041×2 (follow up consultations) were not paid as there was a procedure done and then no consultations payable for four months.

These rejections were directly related to Rule G according to Government Gazette:

Unless otherwise stated, the fee on the WCA Claims in respect of an operation or procedure shall include normal after-care for a period not exceeding four months.

 

In conclusion, when it comes to WCA Claims:

Countless wound care practitioners are undoubtedly being unfairly handled by the Commissioner with this current practice. It is the intention of this journal to continue to highlight injustices of tariff remunerative practices that impact on wound care professionals.

It is the hope that these articles will open the door to discussion and ultimately result in equitable policies for professional services rendered as it pertains to WCA Claims.

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