Burning Issues in Private Healthcare : Audiology. Casper Venter 3 rd November 2015 Managing Director

Transcription

1 Burning Issues in Private Healthcare : Audiology Casper Venter 3 rd November 2015 Managing Director

2 Effective Practice Management Macro Environment Micro Environment

3 Macro Environment International Trends Trends in Africa South African Economy & Future Regulatory Environment Medical Scheme Environment

4 International Trends

5 Top 10 challenges facing USA physicians in 2014 Bendix J, Verdon D, Ritchie A, Marbury D. Medical Economics, Dec 25, 2013

6 Challenge 1 Changing Payment Trends Tighter negotiated payment arrangements with Schemes Escalating cost of doing business Endless bureaucracy and paperwork Example of the Affordable Care Act (ACA) in USA: Consolidation of payer networks (RSA DSPs & DPAs) Increase bargaining power in negotiating contracts with providers Lower cost of care Narrow networks also limit patient choice of provider/hospital Fee-for-service to yield a patient-centered quality outcomes Cost containment, efficiency, aggressive collection policy

7 Challenge 2 USA Government mandates Practices to be affected by 4 government requirements ICD-10 Convert or don t get paid Meaningful Use (MU) Adopt electronic health record systems or face financial penalties from 2015 Health Insurance Portability & Accountability Act (HIPAA) Risk analysis, damage control plan and penalties related to protection of patient health information (RSA - POPI, PAIA ) Patient Quality Reporting System Reports on 138 outcome quality measures. Previously Physicians were incentivised to participate; from 2015 they will be penalised for not. (RSA - OHSC & CPA)

8 Challenge 3 Payer headaches and the fine print Dealings with payers = No 1 physician concern for 2014 Pre-authorisation takes time, costs money No alternative for Physicians Healthcare companies dictate how, or if, physician can treat a patient, prescribe particular medicine or determine length of hospital stay Healthcare companies are dropping doctors from networks

9 Challenge 7 Putting control back in the hands of physicians Job satisfaction in decline Stress, Over regulation, Uncertainty, Workload, Expensive training, Lack of autonomy

10 Challenge 10 Work-Life Balance Burnout Moonlighting by Physicians to earn extra income Early retirement Discouraging children to follow same career path

11 Trends in Africa

12 South African Economy & the Future

13 Challenges for the Future Price Regulation for Private Practice Competition Commission probe into Private Healthcare Change in HPCSA Ethical Rules to improve competition in Healthcare Doctors Employment by Hospitals Multi Disciplinary practices across various Professional Boards Independence of CMS, BHF & HPCSA Changes to Medical Schemes Act PMB & Other NHI White Paper SAMA position on Private Practice and Public Sector Employees

14 Challenges for the Future South African Economy in Rapid Decline Training of Healthcare Professionals Retention of Healthcare Professionals in Private and Public Sector Deteriorating Public Sector Management and Administration Deteriorating quality of Public Sector s quality of Healthcare What will be the impact of Office of Healthcare Standards Compliance (OHSC) Increased Malpractice Insurance Premiums and Claims Reintroduction of the Certificate of Need (CON)

15 Regulatory Environment

16 Present Day Challenges National Health Insurance Competition Commission Genesis Regulation 8 Department of Health & Regulation 8

17 Regulation 8 & PMBs

18 Regulation 8 BHF Genesis DoH

19 Medical Scheme Environment

20 Change in Membership of Medical Schemes over 13 years DHMS Open Schemes (Excl. DHMS) GEMS Restricted Schemes (Excl. GEMS)

21 Medical Scheme Financial Review CMS Report 2014, 2013 and (R Billion) (R Billion) (R Billion) Net Risk Premium Income Gross Healthcare Surplus Administration & Related Expenses (15 405) (14 402) (4 838) Net Surplus for year after Interest Total Member Funds/Surpluses Total Hospital Payments

22 Sustainability of Medical Schemes Industry Review 2013/14 Net Healthcare Surplus (Incl. Investment Income) (R Million) (R Million) (R Million) (R Million) Bonitas Discovery FedHealth (24.5) GEMS (219.2) Momentum POLMED Spectramed (33.2) (15.8) Topmed (10.1)

23 Micro Environment

24 How to Manage an Audiology Practice

25 Micro Environment Audiology as a Profession and Business Opportunity Hearing Institutes and Clinics impact on Independents Supply Chain of Hearing Aids and Equipment Pricing and Coding of Hearing Aids My Own Practice Patients Staff Infrastructure

26 Audiology as a Profession and Business Opportunity

27 Statistical Overview of Audiology Let s look at some of the statistics that generate Audiology services invoices

28 Audiology Claims (R Million) Claimed (R Million) Risk Savings Discovery 139,50 59,44 42,96 Gems 17,59 13,89 0,5 Polmed 18,12 16,89 0 Bonitas 32,71 26,61,70 Bankmed 17,36 14,61 1,25 Momentum 3,06 0,5 1,12 (R per) Member

29 Audiology Claims Patient Visits Unique Patients Cost per Beneficiary Total Beneficiaries Discovery Gems Polmed Bonitas Bankmed Momentum % TOTAL

30 My Own Audiology Practice

31 Audiology Code/Revenue Distribution: R 114 Million Claims 6.70% 7.60% Consultations Procedures & Equipment Hearing Aids 85.70%

32 Revenue Distribution Practice Cost Studies R % Hearing Aids Professional Fees 61.36%

33 Overhead Distribution Practice Cost Studies R Staff Salaries Premises Practice Admin Standard

34 Fees Charged Does the practice have a formal Billing Policy? Single Practice Tariff - Private Rate Only Medical Scheme Tariffs Direct Payment Arrangements Practice Tariff based on DPA, e.g Bestmed Consultation Fee Tariffs Cash, Balance Bill, Split Bill? Consumables Policy and Mark-ups Approved and signed off by Audiologist & Patients Informed Are the above included in Practice Management Software

35 Fees Charged Does the Practice have a Coding Policy or Manual Who does the coding, Audiologist or Admin Staff Are invoices reviewed for errors--- Forensic Reviews Has the Aud/Staff Received Coding Training-Negligence Do you use Fixed Coding Combinations Who deals with coding queries from Funders ignored How do you do corrections? Journals or Credit Note Understand the VAT implications of errors Does the Aud know about the Discounts and write offs

36 Fees Charged Does the Practice do a Monthly Analysis of Fees Tariff and code analysis - frequency and amount Scheme Analysis Patient Numbers Analysis Cash Flow Analysis Invoiced, Received, Written off Outstanding Debtors Analysis, should be less than 30 days

37 Fees Charged Understand Scheme Rules, it has Exclusions, Co- Payments & Hospital Networks Careful Management of Co-Payments and Patient Liable Admin Fees charged at Consultations are not allowed What if Consultation Fees is Higher than DPA Contract Charge Codes even if not Paid by the Scheme What Tariff do you charge if Scheme Rules exclude a benefit and it is a DPA. Don t delay a problem it wont go away

38 Fees Charged Stale Claims & Errors Scheme to notify within 30 days of receipt Resubmit within 60 days of receipt Subject to 4 months as per MSA Problem Schemes Schemes that Merge 4 months period Identify Schemes under Financial Constraints Schemes under Curatorship Be Aware of New Legislation

39 Staff Salaries Largest single Operating Expense Has the Practice had an HR Review of Staffing Policies and Procedures Specialised Field Does the Practice Have SOPS Standard Operating Procedures Are Employment Agreements in Place Do you have Disciplinary Procedures in Place Is SARS correctly being dealt with What Employee Benefits are in Place

40 Infrastructure and Support Information Technology must be current and the best Do you use EDI, Healthbridge or Switch Are you trained in new Switching Modules Do you have Service Level Agreements with IT Suppliers Do you reconcile Switching Transactions When last was the Practice Rental Agreement reviewed? Is Practice equipment adequately insured and you adhere to Maintenance Programmes Do you have a Disaster Recovery Plan?

41 Forensic Inquiries

42 Forensic Inquiries are Based on: Services not rendered to Patients Patient Complaints on pricing and quality of service Coding Outside Scope of Practice Hours per Day charged exceed hours available Supply of Hearing Aids December and January Date of Service and date of Invoice don t agree Excessive mark-ups R16000 R Supplying to Family Members?? Don t require Hearing Aids Not Applying Coding Rules Incorrect Application and Interpretation of Codes Double Billing 3 rd Party Up Coding

43 The End of Business as Usual

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