Category 1
What is the difference between a Referring Doctor and a Locum Doctor?
A Referring doctor is a doctor that directs a
source/patient for help or information to another doctor/specialist.
A locum doctor is a doctor who temporarily
fulfills the duties of another doctor or who works in the place of the regular
doctor when the regular doctor is absent. A locum doctor is also a doctor who
works when a hospital/practice is short-staffed
What is a medical scheme administrator?
The administrator must, on behalf of the medical
scheme, administer the business of a medical scheme in accordance with the Act
and as provided for in the rules of the medical scheme
What are Insured Benefits?
Minimum % a scheme is obligated to pay for non-PMB
True or False:
Reason codes are the VWXY descriptor codes that describes a code and tells you the patients condition.
False
Reason codes are the VWXY descriptor codes indicating the series of events leading to the injury
Name the 3 (three) groups/categories of PMB's?
Chronic
Emergency
Planned procedure
"Rejection = Incorrect dependant code" What do you do when you see this in your relevant department?
Reverse
Validate
Amend
Re-submit
When will you do a credit note?
Incorrect invoicing
Duplicate invoicing
When should a PMB be flagged?
If the
primary ICD10 code is a PMB and only if procedure has been done in hospital
Only in rooms for
Psychology, Psychiatry and Oncology (+ Haematology)
Why do we do patient validation?
To indicate that the patient is a valid member at the Medical Fund,
To confirm that all details of the patient are correct (as per Medical card)
When will you write back a receipt?
Incorrect receipting
Duplicate receipting
What is the purpose of the EDI status to be checked and sending claims via EDI?
To minimise the amount of paper claims,
To eliminate accounts not reaching the Medical fund,
To have proof of delivery
What is a clom and who writes it?
What is a lom and who writes it?
Medical claims involving
PMB and non-PMB cases, we proactively manage in terms of the non-clinical
motivations from a legal and financial spectrum and try to keep the clinical
motivations to a minimum.
We manage all claims including all PMB claims.
Please note that we will manage claims from a legal and financial point of view
and that there may be instances where the medical aid requires clinical
motivations, applicable to both PMB and non-PMB cases, which we would need to
obtain from the clinical specialist.
The clinical motivations are kept to a
minimum due to the fact that we manage the claims proactively and we will
assist with templates as well as all information requested from the medical
aid/s to enable the doctor to compile any required clinical motivations.
What should happen if the first ICD10 code is NOT a PMB, but the second one is?
Contact the rooms and ask what the main condition was.
If rooms confirm that main condition was the second ICD10 code, swop
them around and refer account for PMB review.
List information found on proof of submission and where can I find it?
Dr's details
Patients details
Coding details
Submission reference number
Account - Invoice Line - Edi Response - Extra - Mail proof of submission
In which cases would you do a Journal (Give 3reasons/descriptions)
Where Dr has a No Balance billing or Settlement
Discount Billing policy.
Medicol Process:
Name the three instruction doctor/practice can give for the CC/AM to action after receiving the list of accounts at the end of the month?
Hand over
Further collect outstanding money
Write off
Please give a brief description of what a Medical Aid Payment Arrangement is/entails?
An agreed arrangement between a fund and specialist where the specialist
will be reimbursed as per agreed rates, whether the ICD10 code is a PMB or not
Explain the following:
Split Billing
Balance Billing
No Balance Billing
Split Billing - When two invoices fopr the same date of service gets sent to the patient and medical aid and it is illegal.
Balance Billing - Patient will be held liable for the remaining balance on the account.
No Balance Billing - Patient will not be held liable for the remaining balance on account.
What is the process when a CC/AM finds a billing error on a claim?
Reverse - Account manager
Credit note - Billing department
Re-bill - Billing department
Re-submit - Account manager
List 4 (four) EDI checks/steps to be done every day via the EDI Report:
- To Send
- MFRej (all responses that has
not reached the m/a successfully)
- Check PMB’s flagged in rooms
- Check PMB’s not flagged in rooms
(should be non, unless one of the four specialities)
- Check PMB’s flagged in Hospital
- Check PMB’s not flagged in
Hospital
- Also check Day Clinic if
applicable (should be none?)
List 5 (five) checks of the "Zero Day Process" that should be followed every day?
Explain the notebook sequence
Service
date(s)
• What
you are following up on (PMB or claim follow up)
• Patient
/ medical aid response or feedback
• Your
Action after their response
• Their
reaction / what they have done
• Call reference number
Medical Aid account final step:
Name 5 Medical funds and on which days they should be worked on
a. Discovery - Thursday & Friday
b. MHG - Wednesday
c. Medscheme - Thursdays & Friday
d. Sizwe - Monday
e. Keyhealth - Monday
f. Topmed - Tuesday
g. Medihelp - Friday
h. Momentum - Tuesday
i. Bestmed - Friday
j. UHA - Monday
Name 5 cashbooks and when is it used?
Cash - Used when patient pays with cash
Card - Used when patient pays with card
Electronic - When patient pays via eft
Medical aid - Medical aid pays dr andit reflects on the bank statement
Cheque - When patient pays with cheque at the practice of bank
When disputing a PMB with the medical aid, Provide the 5 questions you will ask the fund to dispute.