Claims Processing Value Chain

Transcription

1 laims Processing Value hain 1. laims Origination 2. laims Determination 3. laims Litigation 4. laims Finalisation 5. Post laims Settlement 1.1. Hospital service centres Summons administration 4.1. apital payment 5.1. Post claims management 1.1. ommunity service centres 2.2. Represented claims 3.2. Writs management 4.2. Legal cost validation 1.2. Document Management * 2.3. Direct claims 3.4. Internal law department (ILD) 4.3. Legal cost payment 1.3. Registration, validation & verification 2.4. Supplier claims 3.5. Magistrate, high & district court litigation 4.4. Writs payment 1.4. Mobile RF 3.6. Panel attorney management 4.5. laims file closure 1.5. Merits 3.7. Judgement monitoring Version 20, 06 June 2013 * Report to orrespondence Manager

2 Symbols and bbreviations Symbols On page reference Off page reference ction Process Decision M - merican ssociation I - ody Identification IF - anking Indemnity Form FS entral rchiving Filing System - ompensation ommissioner LS - Legal and ompliance O - laims Officer OO - hief Operations Officer S - ustomer Service onsultant/entre DM - Document Management DO - Date of ccident Do - Date of irth E - Expenditure uthorisation EIL - Employer Individually Liable ES - Executive Summary GD- General Damages GM - General Manager HM - Hospital ase Manager HPS - Health Professions ouncil Of South frica HS - Hospital Service onsultant/entre IT - Information ommunication Technology ID - Identity Document ILD - Internal Law Department IT - Information Technology LO - Legal ost Officer LoE - Loss of Earnings bbreviations LoS - Loss of Support MMI - Maximum 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 Report SMS Summons Management System SOP - Standard Operating Procedure U number - Undertakings Number U system - Undertakings System U - Unabridged irth ertificate UO - Undertakings Officer V&V - Validation and Verification W - Workmen's ompensation ommission System intervention

3 laims Processing Value hain 1. laims Origination 2. laims Determination 3. laims Litigation 4. laims Finalisation 5. Post laims Settlement 1.1. Hospital service centres Summons administration 4.1. apital payment 5.1. Post claims management 1.1. ommunity service centres 2.2. Represented claims 3.2. Writs management 4.2. Legal cost validation 1.2. Document Management 2.3. Direct claims 3.4. Internal law department (ILD) 4.3. Legal cost payment 1.3. Registration, validation & verification 2.4. Supplier claims 3.5. Magistrate, high & district court litigation 4.4. Writs payment 1.4. Mobile RF 3.6. Panel attorney management 4.5. laims file closure 1.5. Merits 3.7. Judgement monitoring

4 (Part 1 of 3) administrative administrative assitant Receive file from merits/claims Verify all files have been received & acknowledge receipt Peruse file ny documentation outstanding for assessment? Request documentation from claimant/ representative Diarise for follow up Is the claim a medical expense? Print template for medical bill assessment heck for duplicates Serious injury assessment Duplicates found? Record on template for senior review & continue with Verify nexus between injuries, DO & treatment Has nexus been established? Verify that treatment rendered is appropriate Treatment verified? ompare information on account against information on SMR, hospital records (diagnosis and procedure) for senior review & continue with for senior review & continue with

5 (Part 2 of 3) Is the information aligned? heck for over/ under servicing (length of stay & level of care) Over/under servicing identified? heck drug utilisation (amount, frequency, duplication of drugs & drug interaction Drug utilisation verified? heck for preexisting conditions D for senior review & continue with for senior review & continue with for senior review & continue with ill reviewer D re there any pre-existing conditions? for review Prepare file for review by bill review assessor, date & sign file udit & review medical bills and notes made by Does the bill reviewer agree? dvise O to make offer to claimant/ representative for medical expenses for senior review & continue with dvise O to make a revised offer to claimant/ representative for medical expenses

6 Serious injury assessment (Part 1 of 2) administrative administrative Junior/ medical Junior / medical Receive files from bill reviewer or O Verify that all files are available and acknowledge receipt ll files available? Receive file from and review M assessment forms Peruse of all relevant medical documents re all the required documents available? Junior / medical tify medical unit and request outstanding claims Has MMI been reached? Is a medicolegal assessment required? Information verified with the expert? Junior / medical Peruse and assess. pply legal principles, subject to approval by senior Is it a valid GD claim? tify O of finding and accept GD claim D Junior / medical dvise O to diarise in line with expiry date and follow up Junior / medical Request outstanding documentation Junior / medical Junior / medical for senior review and continue with tify O of finding and reject GD claim

7 Serious injury assessment (Part 2 of 2) laims Officer laims Officer laims Officer ook appointment with expert rrange transport & accommodation (where required) Diarise for follow up with expert on receipt of report Direct/Represented Unit

8 laims Processing Value hain 1. laims Origination 2. laims Determination 3. laims Litigation 4. laims Finalisation 5. Post laims Settlement 1.1. Hospital service centres Summons administration 4.1. apital payment 5.1. Post claims management 1.1. ommunity service centres 2.2. Represented claims 3.2. Writs management 4.2. Legal cost validation 1.2. Document Management 2.3. Direct claims 3.4. Internal law department (ILD) 4.3. Legal cost payment 1.3. Registration, validation & verification 2.4. Supplier claims 3.5. Magistrate, high & district court litigation 4.4. Writs payment 1.4. Mobile RF 3.6. Panel attorney management 4.5. laims file closure 1.5. Merits 3.7. Judgement monitoring

9 Represented (Part 1 of 2) dministrative dministrative Senior claims Receive files from medical/merits unit cknowledge receipt of files Senior to determine complexity of claim and distribute to claims s Upon completion of the system development, the allocation of work/files will be done automatically by the system Generate update sms to claimant/ representative ssess and review documentation on file re all the documents available for quantum determination? ssess claim documents (e.g. payslips, medicolegal, hospital records etc. Peruse file to determine if other departments have requested documents Have documents been requested before? Follow up with Plaintiff ttorney (Represented) and diarise accordingly ontact plaintiff attorney and/or generate letter of request Deliver letter to mailroom for delivery Diarise for follow up, update notes on claims view & book file back to FS

10 Represented (Part 2 of 2) Is an expert required? Prepare memo for expert appointment Does senior approve the memo? Senior claims Senior to initiate expert payment and instruct expert to quantify benefits e.g. actuary, industrial psychologist Diarise for follow up and book file to FS Receive and review expert reports D D Quantify value of the benefits pply contingency deductions (apportionment and risk) F onsider any prior payments/interim payments/w/ social grants Prepare an offer Is offer within mandate? Get secondary approval and make offer to claimant Load offer on system & generate update sms to claimant/ representative Is the offer accepted? ccept offer on system, generate acceptance sms & request payment Prepare memo for mandate Reject offer on system Prepare file & deliver to capital payment unit for settlement Revise offer & memo Has memo been approved? F

11 laims Processing Value hain 1. laims Origination 2. laims Determination 3. laims Litigation 4. laims Finalisation 5. Post laims Settlement 1.1. Hospital service centres Summons administration 4.1. apital payment 5.1. Post claims management 1.1. ommunity service centres 2.2. Represented claims 3.2. Writs management 4.2. Legal cost validation 1.2. Document Management 2.3. Direct claims 3.4. Internal law department (ILD) 4.3. Legal cost payment 1.3. Registration, validation & verification 2.4. Supplier claims 3.5. Magistrate, high & district court litigation 4.4. Writs payment 1.4. Mobile RF 3.6. Panel attorney management 4.5. laims file closure 1.5. Merits 3.7. Judgement monitoring

12 Direct (Part 1 of 2) Direct administrative Receive files from medical/merits unit Direct administrative Direct senior cknowledge receipt of files Senior to determine complexity of claim and distribute to claims s Upon completion of the system development, the allocation of work/files will be done automatically by the system Generate update sms to claimant ssess and review documentation on file re all the documents available for determination of quantum? Peruse file to determine if other departments have requested documents ssess claim documents (e.g. payslips, medicolegal, hospital records etc. Did the claimant claim for GD Have documents been requested before? Follow up with Mobile RF or claimant and diarise accordingly an the injuries sustained be declared as serious? dvise claimant to apply for GD as per regulation 3(2)(b) ontact direct claimant and generate letter of request and task for Mobile RF dispatcher dministrative Deliver letter to mailroom or Mobile RF dispatcher Diarise in line with Mobile RF timeline for follow up, update claims view notes, and book file to FS

13 Direct (Part 2 of 2) Is an expert required? Prepare/revise memo for expert appointment Does senior approve memo? Senior claims Senior to initiate expert payment and instruct expert to quantify benefits e.g. actuary, industrial psychologist rrange transport/ accommodation for claimant if physical assessment is required (via Mobile RF) Diarise for follow up and book file to FS Receive and review expert reports Quantify value of the benefits D E D pply contingency deductions (apportionment and risk) onsider any prior payments/interim payments/w/ social grants Prepare an offer Is offer within mandate? Get secondary approval and make offer to claimant Prepare memo within mandate Has memo been approved? Revise offer & memo Load offer on system & generate update SMS to claimant/ representative Is the offer accepted? Reject offer on system ccept offer on system, generate acceptance sms & request payment Prepare file & deliver to capital payment unit for settlement E

14 laims Processing Value hain 1. laims Origination 2. laims Determination 3. laims Litigation 4. laims Finalisation 5. Post laims Settlement 1.1. Hospital service centres Summons administration 4.1. apital payment 5.1. Post claims management 1.1. ommunity service centres 2.2. Represented claims 3.2. Writs management 4.2. Legal cost validation 1.2. Document Management 2.3. Direct claims 3.4. Internal law department (ILD) 4.3. Legal cost payment 1.3. Registration, validation & verification 2.4. Supplier claims 3.5. Magistrate, high & district court litigation 4.4. Writs payment 1.4. Mobile RF 3.6. Panel attorney management 4.5. laims file closure 1.5. Merits 3.7. Judgement monitoring

15 Supplier claims (Part 1 of 2) dministrative Supplier claims senior ill reviewer ill reviewer ill reviewer Receive new claims for assessment cknowledge receipt & verify all claims received against register ll claims received? ssess bill Verify Date of ccident Do verified? Verify injured & details ill reviewer tify H & request outstanding claims Quantum Template: - Verify date of accident - Verify injured - Verify nexus between injuries sustained & treatment - Verify hospital/mbulance records - Verify admission sheets - heck duplicate: verification of payment made to supplier (phone & verify) - Verify that bill has not been settled in full - Record schedule of med expenses ill reviewer and continue with ill reviewer ill reviewer ill reviewer Injured verified? Verify nexus between injuries sustained & treatment Nexus verified? Verify hospital/ ambulance records Hospital/ ambulance records verified? Verify admission sheets dmission sheets verified? ill reviewer ill reviewer ill reviewer ill reviewer and continue with and continue with and continue with and continue with

16 Supplier claims (Part 2 of 2) ill reviewer heck duplicate payments (to ensure that supplier has not been paid already) duplicates found? ill reviewer ill reviewer ill reviewer ill reviewer Record schedule of medical expenses Record any relevant notes for senior to view Record assessed claims on register, bundle & deliver to senior for review pply contingency deductions (merits and risk) and load offer ill reviewer Send to senior for approval ill reviewer and continue with dministrative dministrative dministrative Does senior agree/approve? over claim & record link, ref, supplier name on cover Generate E to be placed on file Deliver file to finalisation ill reviewer Repudiate claim ill reviewer Prepare claim to be delivered to DM for archiving

17 2.4.2 Supplier finalisation Supplier claims senior Receive batch payments from capital payment ll payment requests correct and files available? Supplier claims senior onfirm on batch report and return to capital payment for payment Supplier claims senior heck for paid claims on claims utility bulk Supplier claims system Supplier claims senior hange status of paid claims to F Supplier claims senior Finalise and deliver file FS Supplier claims senior Investigate and make amendments

18 Expert payment laims Officer laims Officer laims Officer laims Officer Prepare a memo to address the situation Is the expenditure within mandate? Forward to senior for approval Memo / expenditure authorization to be forwarded to capital payment for payment Diarise and follow up within 3 days Has payment been made? Senior Officer Forward executive summary to persons with mandate Is the executive summary approved? Senior Officer / Officer Revise the executive summary/expenditure authorization

19 Frequently asked questions in determination What is the difference between the medical unit and the supplier unit aside from advice on narrative? oth units medical vouchers. The medical unit es medical claims when they emanate from a non-supplier (i.e. directly from a claimant/claimant attorney). Supplier units medical vouchers from suppliers/agents Should all medical claims go to the medical unit or only those referred by determination? If we are going to capture all injuries then all files will need to be referred to medical unit if they contain past medical expenses. In addition the supplier staff will need training on capturing injury information. Do medical staff interim payments or is this left to determination? staff should not interim payments (unless in exceptional circumstances) for claims until the functionality to make offers on medical claims independently is implemented. Payments should be made by the determination. Will the type of injury be captured for every claim? The type of injury will be captured for every medical claim when the system has been developed. Will the direct/represented s have access to the merits system? Seniors and team leaders within Determination should have access to amend merits where no merits agreement has been reached or input merits where merits have not been finalised. When will files move to litigation? The litigation criteria will be used for this. This varies from region to region. What is the role of mobile RF? Mobile RF will function as a courier company. They will be responsible for collecting documents and transporting claimants to experts where necessary. Who loads supplier claims and who approves them? ill reviewers load the claim and the senior approves Who will finalise supplier files? The finalisation should be handled in the claims file closure unit.