SUMMARY OF MEDICAL SCHEME PROVIDER NETWORKS FOR GENERAL PRACTITIONERS 2014

Transcription

1 SUMMARY OF MEDICAL SCHEME PROVIDER NETWORKS FOR GENERAL PRACTITIONERS AECI GP NETWORK TARIFF EFFECTIVE 1 JANUARY MEDSCHEME R The AECI GP network model for 2014 also includes the enhanced fee according to the REPI² category score as follows: Category 1 Category 2 Category R R R Please bill at the AECI scheme rate and Medscheme will add the enhanced fee according to your quarterly REPI² score. The General Practitioner plays a very important role as the coordinator of care and it is therefore important that an authorization is obtained by the GP when referring to a specialist. 2. AGILITY RESOLUTION HEALTH MEDICAL SCHEME GP NETWORK TARIFF 2014 Please note that there are two Agility GP agreements available: one for Foundation members (low cost option) and another for members on the higher options, which includes Progressive Flex, Classic, Supreme and the Millennium plans s are: PROGRESSIVE FLEX, CLASSIC, MILLENNIUM & SUPREME OPTIONS TARIFF Acute Consultation plus procedures excluding medicine R Chronic Consultations plus procedures excluding medicine R FOUNDATION OPTION Global Fee: Dispensing Provider including medicine R Global Fee: Non Dispensing Provider R BANKMED TARIFF EFFECTIVE 1 JANUARY 2014 The Bankmed GP provider/ipa Foundation agreement will continue and does not have to be re-signed for Bankmed reimbursement per Scheme plan for 2014: Scheme Plans All other options (Core Saver, Traditional, Comprehensive & Plus) Non-Contracted Provider Contracted IPA Provider Contracted Non-IPA Provider Bankmed Scheme R R Consultation Rate R Completion of PHA No R R HIV Counselling & Testing (HCT) No R R

2 3. BESTMED AGREEMENT WITH GENERAL PRACTITIONERS TARIFF EFFECTIVE 1 JANUARY 2014 As you are aware by now, since 2013 Bestmed has partnered with the IPA Foundation (of which GPMG is an affiliated member) to offer a comprehensive agreement to General Practitioners for The fee structure as set out in Annexure A of the agreement will only apply when profiling has become available: Non-Contracted Profiling Category IPA Foundation and GPMG Non-IPA Provider Provider Contracted Provider N/A Category 1 R R N/A Category 2 R R R Category 3 R (Default fee) R Please note that the Category 3 fee will be the default fee until accurate profiles become available. 4. BMW EMPLOYEES MEDICAL AID SOCIETY change in administrator effective 1 JANUARY 2014 FROM MEDSCHEME TO DISCOVERY As from 1 January 2014, the BMW Employees Medical Aid Society (BEMAS) will be administered by Discovery Holdings. In order to ensure a smooth transition, please take note that claims payments and queries of treatment dates and transactions dated before 1 January 2014 will be dealt with, processed and serviced by Medscheme until 30 April If you have any queries, please call or send an to: bmw@medscheme.co.za. 5. BONITAS GP NETWORK TARIFF EFFECTIVE 1 JANUARY MEDSCHEME R The GP network model for 2014 also includes the enhanced fee according to the REPI² category score as follows: Category 1 Category 2 Category R R R Please bill at the Bonitas scheme rate and Medscheme will add the enhanced fee according to your quarterly REPI² score. 6. BONCAP GP NETWORK TARIFF EFFECTIVE 1 JANUARY MEDSHEME code code description 2014 Global Fee Non-dispensing doctor tariff R Dispensing doctor R Authorisation is required after the 12 th visit. After the 12th visit, benefits for PMB only. Health care services falling under the following tariffs codes may be charged in addition to a consultation (cost of material included) where such health care services are rendered by the Participating Doctor:

3 code code description (including cost of materials) 2014 Global Fee 0206 Intravenous rehydration therapy with or without administration of intravenous antibiotics. R Cauterization of warts/chemocryotherapy of lesions R Drainage of subcutaneous abscess & avulsion of nail R Removal of foreign body superficial to deep fascia R Stitching of a wound R Stitching additional wound R Limb cast (including cost of POP and material) R Drainage external thrombosed pile R Excision and repair R Radical excision of nail bed in rooms R Flow volume test: Inspiration/expiration R Flow volume test: Inspiration/expiration/pre-and post-bronchodilator R Resting ECG (including electrodes) R Circumcision in rooms R HIV rapid test R CARECROSS GLOBAL FEE FOR CONSULTATIONS 1 JANUARY 2014 Carecross pays a global fee for consultations This fee will be communicated by Carecross to each network provider. s for Additional Procedures are: Procedure Code 2014 Description 0300 R R R R R R R R Stitching of wound Stitching of additional wound Excision and repair Each additional small procedure done at the same time Drainage of subcutaneous abscess & Avulsion of nail Removal of foreign body superficial to Deep fascia Circumcision - clamp Limb cast - Inclusive of cost of P.O.P. and other material The above fees are inclusive of 14% VAT. The tariffs for procedures are in addition to the normal consultation fees. 8. CDE TARIFF 1 JANUARY 2014 Healthcare practitioners shall be reimbursed according to their current grading. Details of the grading system are shown in Annexure B of the agreement. Reimbursement rates (Doctors belonging to IPAF and a participation IPA i.e. GPMG) Healthcare Provider Grade CDE Reimbursement Rate for Code 0190 A R per consultation, including VAT B R per consultation, including VAT C R per consultation, including VAT

4 Reimbursment rates (non-members of an IPA i.e. GPMG) Healthcare Provider Grade CDE Reimbursement Rate for Code 0190 A R per consultation, including VAT B R per consultation, including VAT C R per consultation, including VAT Healthcare practitioners shall also be entitled to a monthly retainer fee, payable for each patient (who is an active member of the CDE programme) allocated to them Retainer fee rates: Healthcare Provider Grade A B C CDE Reimbursement Retainer Fee Rate R67.00 per member, including VAT R47.00 per member, including VAT R34.00 per member, including VAT Please note that attendance to a CDE Accreditation course is a CDE accreditation requirement in order to maintain your participation in the CDE Diabetes Management Network. 9. DISCOVERY HEALTH GP NETWORK TARIFF EFFECTIVE 1 JANUARY 2014 GP s in the Discovery Health GP Network: The consultation fee for Discovery Health Medical Scheme and all closed schemes administered by Discovery Health will increase to R345, with the exception of Lonmin Medical Scheme, which will increase to R310. GP s not in the Discovery Health GP Network: The consultation fee for Discovery Health Medical Scheme and certain closed schemes administed by Discovery Health will increase to R310. Consultation rate* for GP s participating in the Discovery Health GP Network Consultation rate* for GP s NOT participating in the Discovery Health GP Network SCHEME NAME Discovery Health Medical Scheme R345 R310 Anglovaal Group Medical Scheme R345 R310 Anglo Medical Scheme R345 R310 BMW Employees Medical Aid Society R345 R310 LA Health Medical Scheme R345 R310 Lonmin Medical Scheme R310 R310 MMED Option of Naspers Medical Fund R345 R310 N Options of Naspers Medical Fund R345 R310 Quantum Medical Aid Society R345 R310 Remedi Medical Aid Scheme R345 R310 Retail Medical Scheme R345 R310 TFG Medical Aid Scheme R345 R310 Tsogo Sun Medical Scheme R345 R310 UKZN Medical Scheme R345 R310 *the consultation rate on codes 0190, 0191 and 0192 *KeyCare plans are excluded: LA Keyplus, Quantum Keyplus and Discovery Health KeyCare plans and KeyCare Access

5 HealthID additional Consultation Fee (excluding KeyCare) R DISCOVERY KEYCARE GP TARIFF EFFECTIVE 1 JANUARY 2014 There will be a 7.8% increase in consultation fees. The 2014 rates are as follows: Code Description FFS Dispensing FFS Non- Dispensing Cap Dispensing Cap Non- Dispensing Consultation R R R R Emergency consultation at doctors' R R R R rooms 0147 Emergency consultation away from doctors' rooms R R R R Procedures performed in rooms There will be a 6% increase in the rate for procedures that GPs can perform in their rooms, once again in excess of CPI at 5.5%. Doctors will be reimbursed irrespective of which network they are on, for the following procedures: Code Description 0255 Drainage of abscess R Removal of foreign body R Stitching of wound R Stitching of additional wound R Excision and repair R POP R Circumcision: Clamp procedure R Circumcision: Surgical excision other than by clamp or dorsal slit, any age R Circumcision: Dorsal slit of prepuce (independent procedure) R FEDHEALTH GP NETWORK TARIFF EFFECTIVE 1 JANUARY MEDSCHEME R The Fedhealth GP Partnership model for 2014 also includes the enhanced fee according to the REPI² category score as follows: Category 1 Category 2 Category R R R Please bill at the Fedhealth GP Partnership tariff and Fedhealth will add the enhanced fee according to your quarterly REPI² score. 12. FEDHEALTH BLUE DOOR GP NETWORK TARIFF EFFECTIVE 1 JANUARY MEDSCHEME GP visit (dispensing) R GP visit (non-dispensing) R207.40

6 12. GEMS GEMS - SAPPHIRE AND BERYL SB GP NETWORK TARIFF EFFECTIVE 1 JANUARY 2014 Dispensing doctor Non-dispensing doctor Authorisation Level 1 R R After 5th visit within network Level 2 R R After 5th visit within network Level 3 R R After 5th visit within network Kindly ensure that you adjust your billing on a quarterly basis according to your REPI category. If you claim incorrectly from GEMS, it may be considered as contract breach! GEMS - RUBY, EMERALD AND ONYX GP NETWORK TARIFF EFFECTIVE 1 JANUARY 2014 GEMS REO GP network consultation fee (Scheme rate) R (Ruby, Emerald & Onyx Options) Enhanced consultation fee applicable to category 1 GP network practices R GLENCORE (PREVIOUSLY XSTRATA ALLOYS) GP NETWORK TARIFF EFFECTIVE 1 JANUARY MEDSCHEME R The Xstrata GP network model for 2014 also includes the enhanced fee according to the REPI² category score as follows: Consultation Category 1 Category 2 Category 3 Code R R R Please bill at the Glencore Medical Aid Scheme rate and Medscheme will add the enhanced fee according to your quarterly REPI² score. 14. LIBERTY HEALTH MEDICAL SCHEME GP NETWORK TARIFF EFFECTIVE 1 JANUARY 2014 The IPA Foundation (of which GPMG is an affiliated member) supports and endorses the Liberty Health agreement. IPA Provider Non-IPA Provider (Returning Clinical information) R R R MBMED TARIFF EFFECTIVE 1 JANUARY MEDSCHEME R The GP network model for 2014 also includes the enhanced fee according to the REPI² category score as follows: Category 1 Category 2 Category R R R

7 Please bill at the MBMED scheme rate and Medscheme will add the enhanced fee according to your quarterly REPI² score. 16. MEDSCHEME IPA FORUM AGREEMENTS (SUMMARY) REPI² CATEGORY 1 REPI² CATEGORY 2 REPI² CATEGORY 3 AECI R R R BONITAS R R R FEDHEALTH R R R MBMED R R R SASOLMED R R R WITS R R R Glencore (Previously Xstrata Alloys) R R R Please remember to always charge the scheme rate in Category 3 and not the fee in Category 1 or 2 even if you fall under these categories. If you qualify for the enhanced reimbursement, Medscheme will automatically calculate the fee and it will be reflected in the last line item of your remittance advice. 17. MEDIHELP NECESSE GP NETWORK TARIFF EFFECTIVE 1 JANUARY Reimbursement rates for Doctors belonging to the IPA Foundation and GPMG: Profiling Category Non-contracted Provider Prescribing Doctors Foundation Contracted Providers Dispensing Doctors IPA Provider Non-IPA Provider IPA Provider Non-IPA Provider Category 1 No benefit R R R R Category 2 No benefit R R R R Category 3 No benefit R Scheme Rate R Scheme Rate R Scheme Rate R Scheme Rate 18. METROPOLITAN GP NETWORK TARIFF EFFECTIVE 1 JANUARY 2014 The Metropolitan GP Network is open to all willing GPs and the benefits of participating include: An enhanced reimbursement rate for consultations. Preferred provider status for services rendered to members of the named schemes. Designated Service Provider (DSP) status for primary care Prescribed Minimum Benefits (PMB). Participating schemes that utilise the Metropolitan GP Network, of which you are entitled to include: Metropolitan Medical Scheme s Premier Option has been participating in the Metropolitan GP network since 1 January The following 2014 reimbursement rates apply: Reimbursement Premier Option Premier Option item model GP consultation: Metropolitan R R % of Scheme rate network - IPA GP consultation: Metropolitan R R % of Scheme rate network - non-ipa GP consultation: non-network Scheme rate R R293.30

8 Imperial Group Medical Scheme s Budget Option has been participating in the Metropolitan GP Network since 1 July Please note that payment is set up differently and the member is required to pay a standardised co-payment of R The following 2014 reimbursement rates apply: item Reimbursement model Budget Option 2014 Scheme payment to GP Member payment to GP GP consultation: Metropolitan network - IPA 110% of Scheme rate R R R43.20 GP consultation: Metropolitan network - non-ipa 105% of Scheme rate R R R43.20 GP consultation: non-network Scheme rate R R R43.20 BP Medical Aid Society has been participating in the Metropolitan GP Network since 1 January The following 2014 reimbursement rates apply: item Reimbursement model BPMAS 2014 GP consultation: Metropolitan network - IPA* 110% of Scheme rate R GP consultation: Metropolitan network - non-ipa 105% of Scheme rate R GP consultation: non-network 80% of Scheme rate R *IPA Independent Practitioners Association Foundation of South Africa 18. MOMENTUM GP NETWORK TARIFF EFFECTIVE 1 JANUARY 2014 The fee structure for 2014 for the Momentum GP Network is as follows: Category Category 1 R Category 2 R Scheme Rate Category 3, 4, 5 R and no category 20. POLMED GP NETWORK TARIFF EFFECTIVE 1 JANUARY 2014 GP Network R The Polmed GP Network tariffs for consultation codes 0190, 0191 and 0192 on both Higher and Lower plans will be R The Polmed non-network tariffs for consultation codes 0190, 0191 and 0192 on both Higher and Lower plans will be R SASOLMED GP NETWORK TARIFF EFFECTIVE 1 JANUARY MEDSCHEME R The SASOLMED GP network model for 2014 also includes the enhanced fee according to the REPI² category score as follows:

9 Category 1 Category 2 Category R R R Please bill at the SASOLMED scheme rate and Medscheme will add the enhanced fee according to your quarterly REPI² score. The General Practitioner plays a very important role as the coordinator of care and it is therefore important that an authorization is obtained by the GP when referring to a specialist. 22. UNIVERSAL HEALTHCARE NETWORK AGREEMENT Universal Network is the Network Division of Universal Care, an accredited managed care organisation within the Universal Healthcare Group. Universal Network is contracted to Medical Schemes, Bargaining Council Health Plans and Occupational Health and Wellness Plans to establish and manage networks of healthcare providers to service beneficiaries/employees in the lower income segments. Beneficiaries/employees are required to nominate a General Practitioner from the list of Universal Network GPs, except for beneficiaries on Transmed Medical Fund, Umvuzo Health and NBCRFLI Health Plan who may visit any Universal Network GP. Name AECI Medical Aid Society CompCare Wellness Medical Scheme Massmart Health Plan National Bargaining Council for the Road Freight and Logistics Industry (NBCRFLI) Wellness Fund Health Plan Tiger Brands Medical Scheme Transmed Medical Fund Umvuzo Health Universal WorkerPlan Occupational Health and Wellness Plan Description of Options AECI Medical Aid Society Value Option CompCare Wellness Medical Scheme MumedED* Network NetworX NetworXED* Massmart Health Plan Network Option NBCRFLI Health Plan Tiger Brands Medical Scheme Mzansi Option Transmed Medical Fund State Plus Network Option Umvuzo Health Standard Ultra Affordable Universal WorkerPlan TruValue TruHealth TruWellness Reimbursement of General Practitioners GPs will be reimbursed according to the following table: Category A and B: Dispensing doctors and Non-dispensing doctors including acute medication 2014 Fees (Inclusive of VAT) Description Level 1 E Level 1 P Consultation fee including acute medication R294 R279 Category C: Non-dispensing doctors excluding acute medication (consultations only) 2014 Fees (Inclusive of VAT) Description Level 1 E Level 1 P Consultation fee excluding acute medication R204 R194

10 Or Capitation Fee where agreed, if more than 50 patients: 2014 Fees (Inclusive of VAT) Description Level 2 E Level 2 P Capitation fee per beneficiary/employee per month Age under 18 years R35 R33 Age years R42 R39 Age 60 years and older R49 R47 Plus: Category A and B Consultation fee per beneficiary/employee per visit. The consultation fee includes the cost of acute medication. R139 R132 All fees are inclusive of VAT. The following codes must be used for all consultations for any acute, follow-up or chronic visits: 0190, 0191 and Plus: Category C Consultation fee per beneficiary/employee per visit. The consultation fee excludes the cost of acute medication. All fees are inclusive of VAT. The following codes must be used for all consultations for any acute, follow-up and chronic visits: 0190,0191 and 0192 R50 R47 Where clinically indicated and where the Universal Network Provider is able and willing to perform the services, no additional fees will be paid for the following codes and beneficiaries/employees will not be required to pay for them: Code Description Emergency consultation 0201 Cost of material 0202 Setting of sterile tray Intravenous treatment Intralesional injections 0225 Epilation 0227 Special treatment of severe acne cases , 0237 Biopsy Treatment of benign skin lesion by chemo-cryotherapy 0244 Repair of nailbed Removal of benign lesion by curetting Fine needle aspiration/aspiration of cyst or tumour 1037 Diathermy to nose or pharynx 1136 Nebulisation (in rooms) Flow volume test ECG/Multi-stage treadmill test 2125, 2127 Destruction of condylomata Electrodessication Removal of tag or polyp or benign lesions Destruction of condylomata 2399, 2400, Biopsy/wedge biopsy , 2962, 2963, 2968 Psychotherapy 3171 Excision of Meibomian cyst 3304 All other physical treatments 3762 Haemoglobin estimation 4050 Glucose strip test 4188 Urine dipstick

11 codes reimbursable over and above the consultation fee: The cost of any consumables will be included in this fee Fees (Inclusive of VAT) Code Description Level 1E and 2E Level 1P and 2P 0255 Drainage of subcutaneous abscess and R R avulsion of nail 0259 Removal of foreign body superficial to R R facia 0300 Stitching of wound R R Suturing of additional wound R67.63 R Excision and repair by direct suture, R R excision nail fold 0887 Limb cast R R No tariff codes or fees will be paid unless pre-authorisation has been obtained and beneficiaries/employees will not be required to pay for them. 23. WITS GP NETWORK TARIFF EFFECTIVE 1 JANUARY MEDSCHEME R The WITS GP network model for 2014 also includes the enhanced fee according to the REPI² category score as follows: Consultation Category 1 Category 2 Category 3 Code R R R Please bill at the WITS scheme rate and Medscheme will add the enhanced fee according to your quarterly REPI² score. 24. INSURANCE PRODUCTS & LOW COST MEDICAL SCHEME OPTIONS Over the last year, various low cost insurance products or medical scheme options have become available in the market. Many of these are setting up GP Designated Service Provider networks and are approaching general practitioners directly and not via the IPA s. Before deciding to participate in these agreements, always consider the following: How many of the patients in your practice will buy into these products?; Can you effectively manage the different terms and conditions as well as fee structures in your practice?; and Are you willing to render services for the fees they are offering? GPMG will be more than willing to advise you on these agreements and you can it to Mardi Roos at roos@healthman.co.za for a response. GENERAL DISCLAIMER The information disclosed above is based on publically-available healthcare industry information which we believe would be of assistance to you. While all care has been taken to supply the correct information, GPMG cannot be held responsible for any losses incurred by a practitioner relying on the above information. Where any doubt exists regarding the eligibility of members, availability of benefits etc., we recommend that the practitioner makes direct enquiries with the relevant schemes.