Claims Processing Value Chain

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Meredith Casey
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1 Claims Processing Value Chain 1. Claims Origination 2. Claims etermination 3. Claims Litigation 4. Claims Finalisation 5. Post Claims Settlement 1.1. Hospital service centres 2.1. Medical 3.1. Summons administration 4.1. Capital payment 5.1. Post claims management 1.1. Community service centres 2.2. Represented claims 3.2. Writs management 4.2. Legal cost validation 1.2. ocument management * 2.3. irect claims 3.3. Internal law department (IL) 4.3. Legal cost payment 1.3. Registration, validation & verification 2.4. Supplier claims 3.4. Magistrate, high & district court litigation 4.4. Writs payment 1.4. Mobile RF 3.5. Panel attorney management 4.5. Claims file closure 1.5. Merits 3.6. Judgement monitoring Version 14, 07 June 2013 * Report to Correspondence Manager

2 Symbols and bbreviations Symbols On page reference Off page reference ction Process ecision M - merican Medical ssociation I - ody Identification IF - anking Indemnity Form CFS Central rchiving Filing System CC - Compensation Commissioner CLS - Legal and Compliance CO - Claims Officer COO - Chief Operations Officer CSC - Customer Service Consultant/Centre M - ocument Management O - ate of ccident o - ate of irth E - Expenditure uthorisation EIL - Employer Individually Liable ES - Executive Summary FCM - Field Case Manager G- General amages GM - General Manager HCM - Hospital Case Manager HPCS - Health Professions Council Of South frica HSC - Hospital Service Consultant/Centre ICT - Information Communication Technology I - Identity ocument IL - Internal Law epartment IT - Information Technology LCO - Legal Cost Officer LoE - Loss of Earnings bbreviations LoS - Loss of Support MMI - Maximum Medical Improvement MV - Motor Vehicle ccident N - ta ene (Important) OR - Official ccident Report P - Panel ttorney POP - Patient Outreach Program RF - Road ccident Fund RF 1 - Road ccident Fund Form 1 RF 2 - Road ccident Fund Form 2 RF 3 - Road ccident Fund Form 3 RF 4 - Road ccident Fund Form 4 RF 5 - Road ccident Fund Form 5 RS - Republic of South frica SPS - South frican Police Service SMR - Statutory Medical Report SMS Summons Management System SOP - Standard Operating Procedure U number - Number U system - System UC - Unabridged irth Certificate UO - Officer V&V - Validation and Verification WCC - Workmen's Compensation Commission System intervention

3 Claims Processing Value Chain 1. Claims Origination 2. Claims etermination 3. Claims Litigation 4. Claims Finalisation 5. Post Claims Settlement 1.1. Hospital service centres 2.1. Medical 3.1. Summons administration 4.1. Capital payment 5.1. Post claims management 1.1. Community service centres 2.2. Represented claims 3.2. Writs management 4.2. Legal cost validation 1.2. ocument management 2.3. irect claims 3.3. Internal law department (IL) 4.3. Legal cost payment 1.3. Registration, validation & verification 2.4. Supplier claims 3.4. Magistrate, high & district court litigation 4.4. Writs payment 1.4. Mobile RF 3.5. Panel attorney management 4.5. Claims file closure 1.5. Merits 3.6. Judgement monitoring

4 Post claims management (Part 1 of 4) Claims Officer Claims Officer Receive undertaking request or retrieve dormant undertaking oes a new undertaking need to be issued? Is the Fund liable? Is claimant still in hospital? ppoint a hospital case (HCM) management Claims Officer L ppoint a field case (FCM) Field case management Claims eterminations epartment irect or Represented claimant? Represented Claims irect Claims raft undertaking certificate Claims Officer Send certificate for senior review oes senior approve the value of the undertaking? Claims Officer Claims Issue undertaking and notify claimant Claims Officer Create File Copies with all information required for undertakings C Consult claimants attorney prior to issuing undertaking Revise certificate

5 Post claims management (Part 2 of 4) C dmin ssistant Receive undertakings certificate from claims department dmin ssistant Locate the claim file by checking on system who last had the file and request accordingly Is the file located? dmin ssistant Retrieve file dmin ssistant Check if undertaking is registered on U system and if it has an excel file Is undertaking registered on U system and does it have an excel file? Receive report from HCM & FCM indicating the condition of the claimant senior dmin ssistant Create dummy file Register undertaking on U system H senior llocate Undertaking to undertakings Make initial assessment of undertaking and create excel file Is the claim a preauthorisation request or medical invoice? etermine clinical appropriateness and correctness Invoice appropriate and correct? Is amount within mandate? E E Undertaking Capture invoice details on excel file pprove authorisation/ invoice L F Check: 1. If the claim is for the claimant 2.fter the date of inception 3. ccident related 4. Reasonable 5. Tariffs if applicable 6. uplicate payment L F

6 Post claims management (Part 3 of 4) senior senior Manager F Print excel spreadsheet and attach invoice for senior review pprove authorisation/ invoice oes the approval require escalation Escalate to relevant level for approval pprove excel spreadsheet and invoice according to mandate G G G Prepare payment list tify claimant and service provider Is there another payment request? H I

7 Post claims management (Part 4 of 4) L Reject invoice/preauthorisation request tify claimant and service provider J Officer Officer Capital payment Capital payment I Is the practice number available? Compare practice number to practice numbers on the service provider table Is service provider registered? Verify legal liability of valid service provider Validate Invoice and check for duplicate payments Initiate payment of undertaking Officer Officer Compare service provider details to RF accredited table K Send invalid service provider details for senior/forensics review Is the service provider accredited with the RF? J Officer iarise and follow up in a week K I

8 management (POP) Visit the patient in the ward ssess claimant situation, compile detailed report Educate claimant on undertaking Compile detailed injury report Plan treatment ttach detailed report to claim to support an interim undertaking to be issued Extent of RF support and commitments RF liabilities and RF policies Pre-existing comorbidities ccident relatedness dvise HSC on which claims are serious and require undertakings ssess and implement treatment plan Communicate plan to all concerned Pre-authorize procedures dvocate for services Procure services Coordinate services Train caregiver(if necessary) Formulate report Monitor the case Status of the client Continuous education on care Equipment allocated to client Revisit the case and determine goal accomplishment, timeliness client, client satisfaction and cost benefit analysis ssess case and discharge from case management when satisfied Client declines or no longer requires service Goals have been achieved further service required Client transferred to another case emise of client Continue communicating with client, caregiver, family and service provider isengagement from client in the event: Client declines or no longer requires service Goals have been achieved further service required Client transferred to another case emise of client ischarge plan and communicate plan to field case

9 management (POP) C Review claimant history, check HCM profile on SharePoint and on file Trace claimant Is the claimant dead? Update file and send to the original undertakings Can you contact the claimant telephonically? Schedule claimant home visit ssess claimant situation, compile detailed report Educate claimant on undertaking Caregiver required? re contact details available? Send an SMS to the claimant and follow up in 2 days C ppoint caregiver Compile detailed injury report Plan treatment ssess and implement treatment plan Communicate plan to all (caregiver, service provider,claims handler) Pre-authorize procedures dvocate for services Procure services Coordinate services Formulate report Monitor the treatment plan physically or telephonically Status of the client Caregiver(continuous education on care) ssistive devices/ equipment allocated to client e.g. check seating in wheelchair or if cushion is still proper. Revisit the case and determine goal accomplishment, timeliness client, client satisfaction and cost benefit analysis ssess case and discharge from case management when satisfied Client declines or no longer requires service Goals have been achieved further service required Client transferred to another case emise of client

10 Plan treatment plan (POP) Hospital/Field case Hospital/Field case Hospital/Field case ssess clinical information available Clinical information adequate? Create clinical case record Create appropriate treatment plan Identify medical interventions necessary Identify related needs of client & family Identify related needs of client & caregiver Identify relevant service providers for client State recommended interventions Identify barriers evelop contingency plan Set target dates Get buy-in of plan to client & family Get consent from all concerned(client, caregiver & family) Hospital/Field case Obtain adequate clinical information Comprehensive emergency Psychological Rehabilitation Community based Vocational Educational needs Financial needs Identify medical interventions necessary Identify related needs of client& family & caregiver Identify relevant service providers for client State recommended interventions Identify barriers evelop contingency plan Set target dates Get buy in of pan to client & family et consent from all concerned(client, caregiver & family)

11 etermine clinical appropriateness and correctness Has a preauthorisation been issued before? Verify invoice against pre authorisation record Is invoice appropriate and correct? ccept invoice pply payment rule Reject invoice Is invoice accepted? Is it a medical invoice? Verify clinical detail Reject invoice mount reasonable? ccept invoice Contact service provider/ claimant to negotiate greement reached? djust invoice / preauthorisation ccept invoice

12 Verify invoice against pre authorisation record ssess authorisation record in terms of service rendered and authorised Invoice different from preauthorisation record? ifference substantiated? Record discrepancy ccept invoice Last invoice? ccept invoice Medical opinion required? istribute invoice to bill reviewer for interpretation Interpret invoice and capture medical evaluation results Record discrepancy Send medical feedback Negotiate with service provider Clinical records substantiate liability? ccept invoice Reject invoice greement reached? djust and accept invoice Reject invoice

13 pply payment rule Check if the Fund is liable Is the Fund liable? Is date of service before undertaking acceptance date? Reject invoice Last invoice? Reject offer uplicate invoice / preauthorisation? Last invoice? ccept invoice Last invoice?

14 Verify clinical detail senior senior Evaluate diagnosis and treatment codes Senior medical opinion required? Invoice distributed to Senior bill reviewer for interpretation Interpret invoice and capture medical evaluation results Send medical feedback Clinical records substantiate liability? Invoice / preauthorisation accepted Update notes on Excel Last invoice item? Contact service provider/ claimant to negotiate C greement reached? djust invoice / preauthorisation Last invoice item? Reject invoice C

15 Prepare payment list ssistant makes copies of signed excel and attaches invoices Generate consolidated list of approved invoices for payment Send list to finance for approval and payment Finance approves? Finance signs, payment is processed Contact undertakings department to resolve query Query resolved? Finance signs, payment is processed Escalate matter and agree on resolution

Claims Processing Value Chain

Claims Processing Value Chain 1. Claims Origination 2. Claims Determination 3. Claims Litigation 4. Claims Supplier claims 6. Post Claims Settlement 1.1. Hospital service centres 2.1. Medical 3.1. Summons