PMBs, DSPs, CDLs SEPs, BULLIES … van Alles en wat nog!
In a previous edition CPC/QualiCare alerted you, our shareholders and members, to the situation regarding your billing rights pertaining to PMBs and CDLs in particular we explained that there was no earthly reason to charge “Scheme Rate” when treating a patient for a PMB or CDL condition, unless you are signed into a Designated Service Provider contract (DSP) with that scheme.
We went on to explain that few specialists have signed DSP arrangements and those who have would not dream of servicing at “scheme rate” (and by that we mean the old NHRPL plus the 6% annual inflators, which have brought you to earn R241.00 for a consultation) This “accepted” benchmark consultation fee offered by the majority of medical aids outside of IPAF, does not value your efforts at cost effective practice in return for fair remuneration and overlooks fee enhancements to the GP offered by more progressive funders in return for Peer review and quality assurance.
The reason why you oblige patients from schemes offering low consultation fee is surely because of your ever present sense of benevolence and altruism combined with the intangible loyalty towards your long standing and often long suffering patients.
Do not forget however, that PMBs and CDLs come out of the scheme pool and not out of patients savings, and as such the scheme has to pay the face value of your invoice without the patient being held liable for a co-payment or a disincentive deduction by the funder. So in essence, unless you signed a DSP contract with a funder, you are entitled to charge that patient well above the “accepted“ benchmark, and the scheme is obliged to pay you at the face value of your invoice. Remember not to transgress the HPCSA’s (unofficial) ethical price ceiling however, and also explain to the patient what you billing and that it is the liability of their scheme. In terms of MCO regulations.
So, for schemes which treat you fairly and play ball, offering higher consultation rates in return for working with IPAF and bringing you Peer review, Peer intervention, Peer management and Peer mentoring, there is an argument to be made to become part of their DSP network. Other schemes however are just big and bullysome. They will try to form DSPs with the arrogant quid pro quo that you, as their DSP doctor, may continue to see their patients. Once such a DSP network is formed, then all nonDSP doctors will be lumbered with not only a copay, but also threatened with hard channelling the patients away from those practices. This top down approach is to be abhorred, together with threats to remove your patient base.
You need to position your practices into the correct space for your community and balance this against your need to make a living.
Watch out for Bullies and remember that IPAF will try to protect you from bad contracts, but YOU are the one who makes the final decision to sign away your rights and be abused.
We have been authoritatively informed that you may sign the low cost contracts with Prosano without being forced to accept any other contract which might have been bundled together with it. Should any of you be coerced or threatened into signing other MCO contracts in order to access your Prosano patients we invite you to inform us urgently and the matter will be referred to the relevant authorities .
Agility / Resolution
Has sent out contracts which appear to be confused with the Resolution Foundation contract. Should you wish to sign the IPAF Resolution contract, please contact CPC/QCare and we will avail you of the correct contract. This requires you to see the patient and perform procedures listed, at no extra charge.
Has sent contract out via IPAF’s posting service. These contracts are not however endorsed by IPAF, although we have had input into the modification of the contracts to make them more GP friendly. We however did not manage to convince the powers that be to make the contract more GP friendly, except for the fact that procedures which are included in the consultation fee, do not have to be performed should the GP not wish to undertake them
Has acknowledged that they erred in their calculation of the medicine pricing, and that they have underpaid the doctors by an indeterminate amount for the past 7 months. Making matters worse, they have erroneously written to doctors since last Xmas threatening them with removal from their preferred provider network as they were deemed to have broken contract by overcharging!!! Watch this space as the matter develops further, and how we shall address their moral obligation to refund you the underpaid amounts
Has released the most convincing figures yet which confirm what we have always said, namely that network doctors who accept Peer review are far more cost effective than their non network counterparts. Bankmed is however keen or our practitioners to improve the number of PHAs performed on their patients in their drive to improving wellness in Bankmed patients. You are strongly encouraged to take up Bankmeds offer, which you may tack onto a consultation when one of the Bankmed patients consult you.
Money for “jam”?
No rather true insight by a leading medical aid into preventative health, brought to you via IPAF and CPC/Qcare.
Peer review and working with your local Peer review officers
Dr Solly Lison and Dr Anil Ramjee are the 2 designated Peer review officers in CPC/Qcare. The have shown their commitment to assisting their colleagues and performing fair, yet effective peer review. Their one problem is that when they call, your receptionists frequently refuse to put them through to you. Please assist them, to help you, and request that your staff connect the call. You may always request them to call back at a better time should they call you during a busy period.
You should all be aware that CPC/Qcare is a foundation member of the SAMCC and as such an integral member of IPAF, upon whose board Tony Behrman acts as treasurer.
SAMCC recently held its AGM and Dr Blinds Nana was re elected to the chair of SAMCC for a second term of office, with Prof Morgan Chetty of KZNMCC as his deputy. Prof Chetty also heads up the Managed care committee together with Dr Behrman, Dr Dennis Dyer and Dr Jeff Govender of PE’s ECIPA group. Dr Solly Lison (CPC/Qcare chairman and head of Peer review) was re-elected as the Financial Director and Gavin April, from ECIPA in PE was re-elected as the secretary.