Hospital Fees Policies & Procedures PDF

**432** +-----------------------------------+-----------------------------------+ | Hospital Fees Policies & | | | Procedures | | +===================================+================================...

**432** +-----------------------------------+-----------------------------------+ | Hospital Fees Policies & | | | Procedures | | +===================================+===================================+ | Sub-directorate: Patient Fees | | | Compliance Auditing & | | | | | | Training | | +-----------------------------------+-----------------------------------+ [Table of Contents] 1. The Uniform Patient Fee Schedule 2 2. Assessment of Patients 5 3. Patient Administration 15 4. Outpatient Attendances 21 5. Inpatient Admissions 27 6. Referrals between Hospitals 33 7. Transport 36 8. The Account Tab 40 9. Foreigners 55 10. Injuries on Duty Cases & Motor Vehicle Accidents 59 11. Projects 62 12. Medical Schemes and Benefit Sick Funds 63 13. Debt Follow-up Processes 67 14. Debt Relief Mechanisms 69 **\ ** **1. THE UNIFORM PATIENT FEE SCHEDULE** **[1.1 Tariff structure]** The Uniform Patient Fee Schedule (UPFS) was developed to provide a simpler charging mechanism for public sector hospitals. This tariff structure is used to raise accounts for services rendered at all healthcare facilities under the auspices of the Department of Health in the Western Cape and to simultaneously generate efficient revenue recovery. The UPFS tariff consists of two (2) parts; a facility fee component and a professional fee component. The **Facility** **Fee** component of the tariff reflects the overhead costs of providing the health care service delivered and is in line with the cost structures associated with the level of the hospital. The **Professional** **Fee** component of the tariff reflects the ultimate responsible professional within a clinic, ward or a hospital, i.e. the professional in the highest capacity responsible for the services being rendered.  The Professional Fee is structured to reflect the costs of the healthcare professionals delivering the service: - Specialist - General Practitioner - Professional Nurse - Allied Health Practitioner **Ultimate Responsible rule** Where more than one category of professional is delivering a service, the **highest** professional level must be charged. No professional fee must be levied where a **private practitioner** is responsible for rendering a service, with exceptions. Private practitioner charges own account. Where a student performs services with or without supervision within a training capacity, the general rule regarding the ultimate responsible professional fee will apply. Where a nurse performs a procedure on prescription of a private practitioner for e.g., IVI Infusion, the Nurse Professional fee should be charged for procedure. The Private Practitioner cannot be charged as the procedure was performed by the nurse and not the private practitioner. **[1.2 Tariff Groupings]** Most UPFS tariffs are based on grouped fees for services rendered, which can be referred to as tariff groupings. Fees are calculated to include overhead costs such as electricity, provision of general equipment, ward stock consumables and pharmaceuticals. The **UPFS tariff groups** are: 01 Anesthetics 14 Emergency Medical Services ---------------------------------------------- --------------------------------------------------- 02 Confinement/Pregnant Woman **15 Assistive Devices and Prosthesis** 03 Dialysis **16 Cosmetic Surgery** 04 Medical Reports **17 Laboratory Services** 05 Imaging **18 Radiation Oncology** 06 Inpatients **19 Nuclear Medicines** 07 Mortuary **20 Ambulatory Procedures** 08 Pharmaceutical **21 Blood & Blood Products** 09 Oral Health **22 Hyperbaric Oxygen Therapy** 10 Consultations **23 Consumables (not included in Facility Fee)** 11 Minor Theatre Procedures **24 Autopsies** 12 Major Theatre Procedures **25 Cosmetic Surgery (Training Purposes)** 13 Treatments/ Supplementary Health Services **[1.3 Classification of Hospitals]** *(FAR 1/2017)* All State hospitals that resort under the Department of Health (DoH) of the Western Cape are divided into three (3) levels and are classified according to the services rendered and who the ultimate responsible professional at that hospital is: Level 1 -- These hospitals are known as **DISTRICT/PROVINCIAL HOSPITALS**. The ultimate responsible professional at these hospitals is a **General Practitioner (GP)**. Level 2 -- These hospitals are subdivided into **PSYCHIATRIC HOSPITALS, INFECTIOUS DISEASES HOSPITALS, SPECIALIST HEALTHCARE FACILITIES and REGIONAL HOSPITALS**. Provincial hospitals refer patients to these hospitals as they render more specialized services. The ultimate responsible professional at these hospitals is a **Specialist**. Level 3 -- These hospitals are known as **ACADEMIC/CENTRAL HOSPITALS**. The ultimate responsible professional at these hospitals is also a **Specialist**, but the difference between an academic and a regional hospital is that an academic hospital is linked to an academic institution for training purposes, such as Tygerberg Hospital that is linked to Stellenbosch University.  *Please note:* In the ***Treated By*** menu on the Account Tab in CLINiCOM the ultimate responsible professional is defaulted according to the level of the respective hospital, but it can still be amended as required.  Excercise Which component of the UPFS tariff will you charge on the invoice in the following scenarios: I. The doctor employed by the hospital, performs duties at a nearby police station\_\_\_\_\_\_\_\_\_\_\_\_\_\_ II. A patient at your hospital chooses a private doctor to perform a procedure at your hospital \_\_\_\_\_\_\_\_\_\_\_\_\_ III. A patient **comes to your hospital for x-rays that will be read by a private doctor\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_** IV. **A patient is treated at the hospital by his/her private doctor while the doctor is working on a sessional basis at the hospital \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_** **\ ** 2. **ASSESSMENT OF PATIENTS** There are different ways how patients are classified, which forms an integral part of Patient Administration. The first differentiation is on the basis of how patients utilize the services of the hospital to be visited. Patients are admitted to the hospital as **INPATIENTS, OUTPATIENTS** or as **BOARDERS**. These classifications will determine the charges to be raised against the patient: An **\"INPATIENT\"** is a patient who is admitted on prescription of a medical practitioner to a bed in a ward or where inpatient treatment is required. C:\\Users\\56061013\\AppData\\Local\\Microsoft\\Windows\\Temporary Internet Files\\Content.IE5\\DSSHGGWA\\large-comic-arrow-pointing-right-0-10773\[1\].gif *Please note:* Most hospitals have a shortage of beds; in these cases the patient will still receive inpatient services even though they may be sitting on a chair. **An \"OUTPATIENT\"** is a patient who is treated at an Outpatient section (clinic) of a provincial hospital. **A \"BOARDER\" is a person** who, with the written authority of the head of an institution, is admitted because in the opinion of a doctor the person\'s presence is essential to the patient\'s recovery in or at such a hospital (This will further be discussed in Section 2.6). Patients are also classified by their household income according to a means test, or whether a third party will be liable for settling the account. **Single Unit** **Family Unit** --------------------------------------------------------------- ----------------------------------------------------------------------------------- A single person, widow/widower, divorcee WITHOUT a dependant. A married couple or a single person, widow/widower, or divorcee WITH a dependant. **[2.1 Financial Responsibilities of Parents/Guardians]** Patients older than 21 years of age who are not registered as a dependant on their parents/guardians' Medical Scheme, are responsible for the settling of their own account, irrespective of whether the patient is a student or living with the parents/guardians. In these cases when the patient receives a bursary, it may not be regarded as income. When the patient is younger than 21 years of age the parents/guardians will be responsible for the settlement of the account, unless the patient is married or employed full time. The parents/guardians of a patient younger than 21 years must be held liable for the settling of the account when the patient is not a dependant on their Medical Scheme, irrespective of whether the dependant stays with the parents/guardians or not. When a patient under 21 years and employed full time is hospitalised and becomes unemployed while in hospital, the responsibility of settling the account falls back to the parents/guardians. Children of divorced parents/guardians must be assessed according to the divorce order where supplied. Liability for the settlement of fees will remain that of the custodian parent. It will be the responsibility of the custodian parent to recover, where applicable, any portion due by the ex-spouse. **[2.2 Employer Details of the Patient]** If the patient is not a recipient of any of the available social benefits, the employment details must be captured by the Reception officer. The **Debt Employer** menu on the Account tab in CLINiCOM is used to select the type of employment the patient belongs to.  The following selections in this menu will be the basis for the category of the patient according to the means test. **2.2.1 Patients who are Civil Pensioners** The patient is a pensioner who has retired from employment in a State Department. Such a patient will be a beneficiary of a GEPF monthly pension.  **2.2.2 Formally Unemployed patients** These patients must submit documentation from the Department of Labor stating that they are unemployed and receive UIF benefits for a specified period. **2.2.3 Informally Unemployed patients** Patients who claim that they are unemployed but cannot provide proof of their circumstances. Usually, an affidavit from a police station will be presented.  **2.2.4 Patients employed by private entities** These patients must provide proof of their income (salary advice) and will be categorised via the means test. **\ ** 5. **Patients employed by State Departments** Patients working for government institutions in the Western Cape can be divided into two groups: - Patients employed by the Department of Health - Patients employed by any department other than the Department of Health.  Patients are categorised into the following groups for the purpose of service fee determination and their ability to pay for health services: [**2.3 Full Paying Patients** ] These include: **2.3.1 Externally Funded patients** Patients for whom a third party will accept responsibility for the payment of the account: I. Medical Scheme patients. II. State Departments, e.g. Department of Correctional Services, South African Police Services, Department of Justice and the South African National Defence Force. III. Statutory bodies - the Workman's Compensation Commissioner (COID) that deals with Injury on Duty cases and the Road Accident Fund (RAF) that deals with motor vehicle accidents. IV. Research Trial Programs funded by a private entity 2. **Self-funded patients** Patients who are responsible for their own accounts who pay full UPFS tariffs: I. **Foreigners/Foreign nationals** -- Patients who are citizens from other countries (Some foreigners are assessed according to their income. These will be discussed in further detail in the chapter on Foreigners) II. Patients treated by their **private doctor** at a provincial hospital. III. Patients utilising the **RGP** (Revenue Generating Project) facilities. **[2.4 Subsidised Patients ]** The fees payable by subsidized patients are calculated as a percentage of the fees payable by full paying patients as determined by the Uniform Patient Fee Schedule (UPFS). Subsidized patients are further categorized based on their ability to pay for health services (according to their monthly/yearly income) into four categories, namely **H0**, **H1**, **H2** and **H3**. 1. **H0 -** Patients in this group receive all services free of charge with certain exceptions. The following types of patients will also be regarded as H0: I. Those who are **Formally Unemployed** - these consist of persons who are unemployed and provide sustaining proof from the Department of Labor that they are receiving monthly benefits from the Unemployment Insurance Fund (UIF) for a specified period. - a sworn affidavit is presented as proof of unemployment - the spouse has an income -- assess as per the family income - the spouse is informally unemployed -- the H1 tariff is then applicable II. Patients that have been placed in the H0 category for the duration of their treatment under the **Delegation 5** authority, due to their financial circumstances. III. **Social Grant** beneficiaries -- those who receive a grant/benefit as determined by the Department of Social Services on a yearly basis or for a specified period. The grants currently available to beneficiaries, who may qualify as per a means test, are as follows: - **Old Age Grant** -- this grant is intended for persons 60 years and older, who do not receive any other remuneration. - **Disability Grant** -- this grant is intended to provide for the basic needs of adults (people who are between 18 and 59 years) who are unfit to work due to a mental or physical disability. The disability must be confirmed via a valid medical report by a medical officer stating whether the disability is temporary or permanent. - **Child Support Grant** -- This grant is intended for a primary care giver of a child. If the recipient is not the biological parent of the child, proof must be provided of primary care giver status. This can be an affidavit from a police official, a social worker's report, an affidavit from the biological parent of the child, or a letter from the school principal of the child. Children must be under the age of 18. - **Care Dependency Grant** - The Care Dependency Grant is given to the caregivers of children with disabilities. The child must be found permanently and severely medically disabled by a medical officer and must be under the age of 18. - **War Veteran's Grant** -- this grant is intended for people who fought in World War I, World War II or the Korean War. The recipients must also be disabled, or over the age of 60 years. - **Foster Care Grant** -- this grant is intended for a care giver of a child under the age of 18 years, with a court order indicating that the care giver has been designated as the foster care giver of the child. These may include a foster parent, an orphan's home or an industrial school. - **Grant-in Aid --** this grant is for persons already receiving a disability grant, war veteran's grant or old age grant, who are not able to look after themselves due to a physical or mental disability, and therefore need full-time care from someone else - **Social Relief of Distress** - this is a temporary provision of assistance intended for persons in such dire material need that they are unable to meet their families\' most basic needs. Assistance will be for 3 months, but can be extended to 6 months. **2.4.2 H1 --** Patients in this category pay an all-inclusive fee when their visit or admission is registered. - These patients will be assessed according to the means test with yearly incomes of less than R70 000 for a single person and less than R100 000 for a family unit. - This category is the default classification for a person without an income **(informally unemployed)**, or if no proof of a monthly benefit from the Unemployment Insurance Fund (UIF) can be submitted. - The upfront fee does not include Emergency Medical Services (EMS), Patient Transport (Healthnet), or Assistive Devices (e.g., crutches and walkers). **2.4.3 H2 --** Patients in this group are subsidized at a percentage of the fees payable by full paying patients. These patients will be assessed according to the means test with yearly incomes of R70 000 -- R250 000 for a single person and R100 000 -- R350 000 for a family unit. **2.4.4 H3 --** Patients in this group exceeds the means test with yearly incomes greater than R250 000 for a single person, and greater than R350 000 for a family unit. **[2.5 When Debtor information is not available]** **2.5.1 Unknown Patients** Invoices for patients who cannot provide any relevant debtor information will be raised at zero rates. These cases must be followed up regularly by the Reception staff until the debtor information becomes available, as well as when the patient is transferred to another hospital.  **2.5.2 Confirmed Unknown Patients** The selection below must be used when it is confirmed that patients that have been registered as **Unknown Patient**, will never be able to provide any debtor information; the invoice will be zero rated. **Patient Assessment Matrix** +-----------------+-----------------+-----------------+-----------------+ | **Patient** | **Debtor** | **Classificatio | **Clinicom | | | | n** | Selection** | +=================+=================+=================+=================+ | Dependent under | Parents/guardia | Means test | Select "Other" | | 21 and receives | ns | | | | no grant | receives social | If dependent is | Do not select | | | grants | under 6 the | social grant | | | | system will | | | | | automatically | | | | | zero rate the | | | | | invoice | | | | | otherwise it | | | | | will be H1 | | +-----------------+-----------------+-----------------+-----------------+ | Dependent under | Parents/guardia | Means test | Select "Other" | | 21 and receives | ns | | | | no grant | receives | If dependent is | Select | | | unemployment | under 6 the | "Informally | | | benefits | system will | unemployed" | | | | automatically | | | | | zero rate the | | | | | invoice | | | | | otherwise it | | | | | will be H1 | | +-----------------+-----------------+-----------------+-----------------+ | Dependent under | Parents/guardia | H0 | Select "Other" | | 21 and receives | ns | | | | grant | are employed | | Select "Social | | | | | Pensioner" type | +-----------------+-----------------+-----------------+-----------------+ | Dependent under | Single mother | Means test | Select "Other" | | 21 and receives | also under 21 | | | | no grant | and dependent | If dependent is | Select | | | on parents | under 6 the | "Informally | | | | system will | unemployed" | | | | automatically | | | | | zero rate the | | | | | invoice | | | | | otherwise it | | | | | will be H1 | | +-----------------+-----------------+-----------------+-----------------+ | Parent is | Parents/guardia | Means test | Select "Other" | | patient | ns | | | | | who receive a | | Do not select | | | grant on behalf | | social grant | | | of the child. | | | | | Child is the | | | | | recipient of | | | | | the grant | | | +-----------------+-----------------+-----------------+-----------------+ | Wife/husband/li | Husband/wife/li | H0 | Select "Other" | | fe | fe | | | | partner | partner | | Select | | receives no | receives social | | "Formally | | grant but | grants | | Unemployed" | | formally | | | | | unemployed | | | | +-----------------+-----------------+-----------------+-----------------+ | Wife/husband/li | Husband/wife/li | Means test | Select "Other" | | fe | fe | | | | partner | partner | | Do not select | | employed | receives social | | social grant | | | grants | | | +-----------------+-----------------+-----------------+-----------------+ | Wife/husband/li | Husband/wife/li | Means test | Select "Other" | | fe | fe | | | | partner | partner | | Do not select | | informally | receives social | | social grant | | unemployed | grants | | | +-----------------+-----------------+-----------------+-----------------+ | All | Debtor has | Means test | Select "Other" | | cases/homeless | always been | | | | patients | unemployed and | | Select | | | can never | | "Informally | | | produce proof | | unemployed" | | | of | | | | | unemployment. | | | | | | | | | | Affidavit must | | | | | be produced in | | | | | this instance. | | | +-----------------+-----------------+-----------------+-----------------+ **[2.6 Boarders and Escorts]** Boarders do not receive any medical care, but are accommodated in a hospital ward or staff residence. Boarder fees are payable in advance and is determined by the expected period the boarders will be accommodated and the income category of the patient that they accompany. The following table explains the definitions of the different types of Boarders and the relevant selections on the Boarder and Escort Function in CLINiCOM. +-----------------------+-----------------------+-----------------------+ | BOARDER SELECTION | DEFINITION | FEE | +=======================+=======================+=======================+ | **Boarder Essential P | **Boarder Type: BOR | The classification of | | at Recovery** | (Boarder)** | the boarder is based | | --------------------- | | on the debtor details | | ------------- | **Billing Code : 01 | related to the | | | (Boarder)** | patient. | | ***Clinicom Code: BOR | | | | 01*** | **Admin Code : BOR | H0 and H1 cases are | | ===================== | (Boarder)** | Free. | | ===== | | | | | A person who, with | | | | written authority, is | | | | **admitted** because | | | | in the opinion of the | | | | doctor the person's | | | | presence is essential | | | | to the patient's | | | | recovery. | | +-----------------------+-----------------------+-----------------------+ | Well New Born Live-in | **Boarder Type: BOR | All cases are Free | | Hospital | (Boarder)** | | | --------------------- | | | | --------- | **Billing Code : 02 | | | | (Live-In Baby)** | | | *Clinicom Code:BOR02* | | | | | **Admin Code : BLIVE | | | | (Live Baby)** | | | | | | | | This is a Live-in | | | | Baby accommodated in | | | | the **Ward** who is a | | | | new-born infant of a | | | | mother still a | | | | maternity patient and | | | | does not require any | | | | special medical care. | | +-----------------------+-----------------------+-----------------------+ | **Live-in Child Cared | **Boarder Type: BOR | The classification of | | for by Mother** | (Boarder)** | the boarder is based | | --------------------- | | on the debtor details | | ---------------- | **Billing Code : 03 | related to the | | | (Live-In Child)** | patient. | | Clinicom Code: BOR03 | | | | | **Admin Code : BOR | H0 and H1 cases are | | | (Boarder)** | Free. | | | | | | | An infant who is | | | | A**dmitted** to a | | | | hospital but does not | | | | receive any nursing | | | | or medical care, and | | | | who is cared for and | | | | fed by the mother | | | | while she is a | | | | patient. | | +-----------------------+-----------------------+-----------------------+ | **Pat Companion Relat | **Boarder Type: BOR | The classification of | | ive/Friend** | (Boarder)** | the boarder is based | | --------------------- | | on the debtor details | | ------------ | **Billing Code : 04 | related to the | | | (PatientCompanion)** | patient. | | Clinicom Code: BOR04 | | | | | **Admin Code : BOR | A tariff equivalent | | | (Boarder)** | to the tariff | | | | applicable to the | | | A family member or an | patient who is | | | acquaintance of a | accompanied is | | | hospital patient who | charged in all cases. | | | accompanies such a | | | | patient without any | | | | official reasons to a | | | | state hospital and | | | | requires | | | | accommodation in a | | | | **Ward** because | | | | he/she has no | | | | alternative | | | | accommodation. | | +-----------------------+-----------------------+-----------------------+ | **Pat Companion Board | **Boarder Type: BOR | Board and Quarter Fee | | & Quarters** | (Boarder)** | | | --------------------- | | | | ------------- | **Billing Code : 05 | | | | (PatientCompanion | | | Clinicom Code: BOR05 | Board & Quarters)** | | | | | | | | **Admin Code: BOR | | | | (Boarder)** | | | | | | | | This is a | | | | breastfeeding | | | | mother/family member | | | | or an acquaintance of | | | | a hospital patient | | | | who accompanies such | | | | patient without any | | | | official reasons to a | | | | state hospital and | | | | requires | | | | accommodation in the | | | | **Staff Residence or | | | | the Special Boarding | | | | Ward at TBH** because | | | | he/she has no | | | | alternative | | | | accommodation. | | +-----------------------+-----------------------+-----------------------+ +-----------------------+-----------------------+-----------------------+ | BOARDER SELECTION | DEFINITION | FEE | +=======================+=======================+=======================+ | Escort Appointed | **Boarder Type: ESC | Board and Quarter Fee | | | (Escort)** | | | *Clinicom Code:BOR06* | | | | | **Billing Code : 06 | | | | (Escort)** | | | | | | | | **Admin Code : ESC | | | | (Patient Escort)** | | | | | | | | A person specifically | | | | **Appointed** to | | | | accompany a hospital | | | | patient to or from a | | | | state hospital and | | | | who is normally | | | | accommodated in the | | | | Staff Residence when | | | | accommodation is | | | | required. | | +-----------------------+-----------------------+-----------------------+ | Relative Assist With | **Boarder Type: BOR | All cases Free | | Diagnosis | (Boarder)** | | | | | | | *Clinicom Code: | **Billing Code : 07 | | | BOR07* | (Relative)** | | | | | | | | **Admin Code : BOR | | | | (Boarder)** | | | | | | | | A family member of a | | | | patient who, with | | | | written authority, is | | | | admitted for | | | | examination in order | | | | to assist with the | | | | diagnosis of the | | | | condition of such | | | | patient. | | +-----------------------+-----------------------+-----------------------+ | Boarder Awaiting Tran | **Boarder Type: BOR | Debtor details must | | sport | (Boarder)** | be recorded. | | --------------------- | | | | ----- | **Billing Code : 08 | The applicable | | | (Patient Boarder)** | general ward tariffs | | *Clinicom Code:BOR08* | | are charged in all | | | **Admin Code : BOR | cases. | | | (Boarder)** | | | | | | | | A patient who has | | | | been discharged and | | | | is accommodated in a | | | | **Ward** awaiting | | | | transport. | | +-----------------------+-----------------------+-----------------------+ | Board &Quarters Await | **Boarder Type: BOR | Board and Quarter Fee | | Transport | (Boarder)** | | | --------------------- | | | | ---------- | **Billing Code : 09 | | | | (Patient Board & | | | Clinicom Code: BOR09 | Quarters)** | | | | | | | | **Admin Code : BOR | | | | (Boarder)** | | | | | | | | This is where a | | | | patient has been | | | | discharged and is | | | | accommodated in the | | | | **Staff** **Residence | | | | or the Special | | | | Boarding Ward at | | | | TBH** awaiting | | | | transport. | | +-----------------------+-----------------------+-----------------------+ | Patient Companion Bre | **Boarder Type: BOR | The classification of | | astfeeding Mother | (Boarder)** | the boarder is based | | --------------------- | | on the debtor details | | ----------------- | **Billing Code: 04 | related to the | | | (PatientCompanion)** | patient. | | Clinicom Code: BOR10 | | | | | **Admin Code: BOR | A tariff equivalent | | | (Boarder)** | to the tariff | | | | applicable to the | | | A mother of a | patient who is | | | hospital patient | accompanied is | | | still requiring | charged in all cases. | | | breastfeeding and is | | | | accommodated in a | | | | **Ward** because she | | | | has no alternative | | | | accommodation. | | +-----------------------+-----------------------+-----------------------+ | **Boarder to Attend C | **Boarder Type: BOR | Debtor details must | | linic** | (Boarder)** | be recorded. | | --------------------- | | | | ------- | **Billing Code : 08 | The applicable | | | (Patient Boarder)** | general ward tariffs | | Clinicom Code: BOR11 | | are charged in all | | | **Admin Code : BOR | cases. | | | (Boarder)** | | | | | | | | An outpatient who is | | | | accommodated in a | | | | **Ward** waiting to | | | | attend a Clinic. | | +-----------------------+-----------------------+-----------------------+ +-----------------------+-----------------------+-----------------------+ | BOARDER SELECTION | DEFINITION | FEE | +=======================+=======================+=======================+ | Board & Quarters To | **Boarder Type: BOR | Board and Quarter Fee | | Attend Clinic | (Boarder)** | | | | | | | Clinicom Code: BOR12 | **Billing Code : 09 | | | | (Patient Board & | | | | Quarters)** | | | | | | | | **Admin Code : BOR | | | | (Boarder)** | | | | | | | | An outpatient is | | | | accommodated in the | | | | **Staff** **Residence | | | | or the Special | | | | Boarding Ward at | | | | TBH** waiting to | | | | attend a Clinic. | | +-----------------------+-----------------------+-----------------------+ | Well New Born En Rout | **Boarder Type: BOR | All cases are Free | | e To Hosp | (Boarder)** | | | --------------------- | | | | --------- | **Billing Code : 02 | | | | (Live-In Baby)** | | | *Clinicom Code: | | | | BOR13* | **Admin Code : BLIVE | | | | (Live Baby)** | | | | | | | | This is a Live-in | | | | Baby accommodated in | | | | the **Ward** who is a | | | | new-born infant of a | | | | mother still a | | | | maternity patient and | | | | does not require any | | | | special medical care. | | +-----------------------+-----------------------+-----------------------+ **Excercise** 1. List the three ways in which a patient will fall in the H0 category \_\_\_\_\_\_\_ 2. How must boarder fees be charged? Is it done this way at your hospital? \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ 3. **How will you register a patient who provides proof that they receive a Child Support Grant for their child?\_\_\_\_\_\_\_\_\_** 4. **Indicate whether the following patients will be regarded as a single person or a family unit:** a. **The patient is married \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_** b. **The patient is not married but has a 13 year old son \_\_\_\_\_\_\_\_\_\_\_\_\_\_** c. **The patient is single with no children \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_** d. **The 25 year old patient is not married but her mother lives with her permanently \_\_\_\_\_\_\_\_\_\_\_\_** e. **The patient has a 17 year old son and 24 year old daughter \_\_\_\_\_\_\_\_** f. **The patient is a widow with an 18 year old son \_\_\_\_\_\_\_** PATIENT ADMINISTRATION *(FAR 9/2017)* ------------------------------------- **[3.1 Documentation]** When a patient visits the hospital for medical services, the following documentation must be provided to the Reception officer and updated copies must be filed in the patient's folder: - Identity Document. - A Referral Letter from a private doctor, clinic or other hospital. - Appointment Card. - Proof of the patient's residential address e.g. a Municipal Account. - Original Pay Slips - with the combined gross family income. - Medical Scheme Card -- if the patient is a member of a medical scheme. - Proof of formal unemployment - Letter from Department of Labour. - Proof of Social Grants -Letter, SASSA Card with statement of next pay-out dates or a Bank Statement reflecting the payments. - Permit/ Visa/Passport - If the patient is a foreigner. - Authorization form for State Department patient: - SAP70 (South African Police Services) - G111 (Department of Correctional Services) - DD2703/63 (South African Defence Force) - J138 (Department of Justice) These documents and all other information must be reviewed and verified with the patient at every visit. **[3.2 Patients without written proof]** - Formally unemployed persons who cannot produce the required documents must be assessed according to the means test. - Social pensioners in receipt of an Old Age Grant who only present a SASSA card and proof of identification (ID) shall be assessed as H0. - Social pensioners in receipt of a grant other than an Old Age Grant who only present a SASSA card and proof of identification (ID) shall be assessed as H0 for the first three visits and thereafter according to the means test. - Patients can also be placed in the H3 category by selecting Maximum for either of the following reasons: - If patients have not produced proof of income for - If patients refuse to declare their income, they must be assessed at the H3 category. The administration form must be endorsed accordingly **[3.3 Folder Management]** Folders for patients with booked appointments must be drawn as per the picking list from the Medical Records department a day before the appointment. All admission and registration forms must be printed and signed, including direct admissions to wards. Valid reasons must be recorded on the form where signatures cannot be obtained, e.g. when the patient is unconscious at time of admission and died before a signature could be obtained. Folders must be transferred on the CLINiCOM system (Casenote Tracking) at the receiving point where patients are referred from one clinic or ward to another. **[3.4 Process Flow]** As patients are classified based on their household income or financial circumstances, they are billed for healthcare services rendered to them according to the tariffs applicable to their classification. **3.4.1 H0** patients must produce proof of their social and financial circumstances. **3.4.2 H1** patients must submit proof of their income. **H1** patients, who attend two or more outpatient clinics on the same day, are **assessed for the most expensive clinic**, irrespective of the number of clinics they attended. The tariff applicable to H1 **inpatients** is for each 30 days or part thereof.  The equivalent of a consultation or inpatient fee must be raised when medical services are provided to H1 patients, as there is no differentiation in the type of consultation or bed type. When H1 patients have already been discharged and returns later on the same day, they must be assessed again. **3.4.3 H2, H3 and Full Paying Patients** are billed according to a 12 hour rule. This means that depending on the time of day the attendance or admission is recorded, they will be billed for the 12 hour period in which their admission time falls, whether it is between 00H00 and 11H59 from midnight to midday or 12H00 and 23H59 from midday to midnight. **H2, H3 and Full paying patients** who attend two or more clinics on the same day, are **assessed for each visit** at each clinic. **3.4.4 Statutory Free Services** must be rendered for free according to legislation, irrespective of the income classification of the patient. **3.4.4 Non-subsidized Services** are excluded from subsidization and should be paid for in terms of the prescribed full paying tariffs: - Issuing of medical reports and copies of x-rays, as well as the completion of certificates/forms - Cosmetic surgery - Contested fatherhood tests (HLA and DNA typing) - Immunization for foreign travel purposes - Work evaluations - Autopsies - Mortuary Fees **[3.5 Payment of Fees]** Deposits recorded against the name of the patient may occur when no admission or attendance was registered at the time of the payment. The deposit will be transferred to the accounts programmatically when the admission is registered in CLINiCOM. When scheduling outpatient visits or admissions, patients must be informed either telephonically, via SMS or the booking-letter system of the applicable fees payable at the time of visit. **3.5.1 H1 Patients** - Patients are required to pay for services at the time of visit or admission. Reception or admission staff must request payment upfront for services. - Where the patient is unable to pay the fee, an invoice must be printed and handed to the patient at time of admission or visit. **3.5.2 H2, H3 and Full Paying Patients** - Patients must pay a deposit equal to two thirds of the projected cost of the patient stay in the facility for booked cases. - Reception or admission staff must request deposit upfront for services. - The Case Manager at the relevant hospital must assist admission staff with the calculation of the deposit where necessary. - The billing system can also be used for estimations.  - Where the required deposit was not paid, patients must be referred to the Hospital Fees Department to make the necessary payment arrangements. Notes must be made on the Patient Administration System of any payment arrangements, and must be followed-up at the next visit. **3.5.3 Credit Card Payments** Hospital staff must ensure that debit/credit card machines are easily accessible in order to facilitate payment of fees. Payments from foreigners using the major foreign credit cards are only accepted when it displays the Visa or Maestro logo. Money must be transferred to the Visa Rand Travel Card which is accepted, as it will have the VISA or Maestro logos. **[3.6 Cancellation of payments]** A payment made against an admission or visit that must be cancelled, must first be allocated to any outstanding invoices. If there aren't any it must be refunded. A receipt can only be cancelled if the original is handed in. Money can only be refunded from the cash on hand if the closing of cashier sessions as per determined periods have not yet been performed. If this process has already been performed, refunds should be made through petty cash. Where a receipt must be cancelled and the original is not available a declaration signed by the supervisor and the cashier is required before a refund can be made. In the case where a receipt is damaged and the patient insists on an original receipt, a certified copy must be provided. Excercise 1. When does a H1 patient pay at your hospital and what services does it include?**\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_** 2. **Indicate whether the following patients will be billed as full paying (externally funded) or according to their income (means test):** 1. **The patient was in a motor vehicle accident\_\_\_\_\_\_\_\_\_\_\_** 2. **A medical aid patient \_\_\_\_\_\_\_\_\_\_\_** 3. **An H3 patient\_\_\_\_\_\_\_\_\_\_\_** 4. **A patient with a work injury \_\_\_\_\_\_\_\_\_\_\_** 5. **Patient brought in with a SAP70 as source document\_\_\_\_\_\_\_\_\_\_\_** 3. **When must the Notes function be used?\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_** 4. When will a person **fall in the H3 category? \_\_\_\_\_\_\_\_\_\_\_** 5. **Name the documents that must be produced when a patient is assessed. Why are these documents so important?\_\_\_\_\_\_** 6. **Why would an admission form not be signed by a patient?\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_** 7. **What is the 12hour rule?\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_** 8. **How will you register a patient who only brings a SASSA card and an ID?­\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_** 9. **How will you register a patient who refuses to disclose their income in CLINiCOM?\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_** 3. **OUTPATIENT ATTENDANCES** [**4.1** **ER and Outpatient clinics** ] These visits must be recorded in the Attendance screen as seen below.  The Attend Status field records what happens on the day that the patient visits the hospital as an outpatient. Selections available are as follows: - **Attended** - An appointment was made for a specific day and clinic and the patient kept to the appointment. - **Cancelled on day** - An appointment was made for a specific day and clinic, but the patient cancelled the appointment and did not attend the clinic, or the appointment is cancelled by the hospital. - **Did not attend** - An appointment was made for a specific day and clinic, but the patient did not turn up for the appointment. - **Walk In** -- The patient attends an outpatient clinic, usually the ER, without an appointment. The Attend Charge field records how a patient will be billed for the outpatient visit, i.e. if the patient was tended to: - **Visit Fee** - When a patient is seen by a Doctor in an outpatient clinic, the standard consultation fee will be charged. - **Emergency** - When a patient is treated in the Trauma or Emergency area without an appointment. Emergency Consultation tariff will be charged. - **Home visit** - when full paying patients are visited at their homes, the applicable routine consultation fee, plus additional services and the prescribed kilometre tariff or official vehicles must be charged. This service is free for H0, H1, H2 and H3 patients. - **Post-Operative Visit** - Patients who return for uncomplicated post-operative care within 6 weeks following a procedure, on an outpatient basis. The procedure code in the UPFS procedure codebook will indicate whether aftercare is in /excluded in the original procedure (excluding after complications). No consultation fee will be charged when this selection is made unless medication was prescribed (applies to first visit only and it is only applicable for State Hospitals). - **Services Only** - When a patient does not see a doctor, but only receives a service e.g. - **Visit Off-site** -- The Department of Health works with state departments on the basis of SLA's to provide services to patients at various institutions. Tariffs for doctors to visit these institutions are determined in the contract. - **Same Day Attend H1** - When an H1 patient attends more than one clinic on the same day and for the same episode, only one visit fee should be charged. No consultation fee will be charged for the other clinics visited. **\\** - **Telephone Consultation** -- This selection is made when a specialist consults with a patient **via the telephone**. This type of consultation occurs when the patient is unable to physically attend the hospital or certain requirements/regulations which does not permit the patient to come in contact with other patients for e.g., COVID-19 social distancing. **[4.2 Outpatient Services for Inpatients]** When a patient must receive treatment at an outpatient clinic during an inpatient stay, the outpatient services must be linked to the admission in order for one invoice to be created, e.g. when an inpatient must receive physiotherapy. This is especially important when invoices must be submitted for payment with regard to treatment of Externally Funded patients. When the "Referral INP ADD" function on the "Outpatient" menu in CLINiCOM is used, the outpatient service will automatically be added to the invoice for the admission of the patient. A yellow note with black text Description automatically generated with low confidence **[4.4 Comprehensive Packages]** - **The rules regarding Comprehensive Packages are only valid for H1, H2 and H3 patients; and include the following:** +-----------------+-----------------+-----------------+-----------------+ | Treatment | H1 | H2 | H3 | +=================+=================+=================+=================+ | Dialysis (on an | Six visits | Six visits | Six Visits | | outpatient | (OPVIS) and | (OPVIS) and | (PD031, PD032 & | | basis) | zero rate the | zero rate the | PD033) and zero | | | rest of the | rest of the | rate the rest | | (Haemo-dialysis | visits per 30 | visits per 30 | of the | | , | day period | day period | procedures per | | Peritoneal | | | 30 day period | | dialysis, | **(Ultimate | **(Ultimate | | | Plasmapheresis) | Professional | Professional | **(Ultimate | | | fee rule | fee rule | Professional | | | applies)** | applies)** | fee rule | | | | | applies)** | +-----------------+-----------------+-----------------+-----------------+ | PUVA (on an | Six visits | Six Ambulatory | Six Ambulatory | | outpatient | (OPVIS) and | Procedures | Procedures | | basis) | zero rate the | (P0228, P0229, | (P0228, P0229, | | | rest of the | P0230 & P0231) | P0230 & P0231) | | (ultra-violet | visits per 30 | and zero rate | and zero rate | | treatment) | day period | the rest of the | the rest of the | | | | procedures per | procedures per | | | **(Ultimate | 30 day period | 30 day period | | | Professional | | | | | fee rule | **(Ultimate | **(Ultimate | | | applies)** | Professional | Professional | | | | fee rule | fee rule | | | | applies)** | applies)** | +-----------------+-----------------+-----------------+-----------------+ | Allied Health | Five visits | Five visits | Five visits | | -- Service | \[Consultation | \[Treatment | \[Treatment | | Groups | (SGCON), | (SGTRT) or | (SGTRT) or | | (Outpatients) | Treatment | Group Therapy | Group Therapy | | | (SGTRT) or | (SGGRP)\] and | (SGGRP)\] and | | | Group Therapy | zero rate the | zero rate the | | | (SGGRP)\] and | rest of the | rest of the | | | zero rate the | visits per 30 | visits per 30 | | | rest of the | day period | day period | | | visits per 30 | | | | | day period | (Initial OPD | (Initial OPD | | | | Consultation | Consultation | | | | not included) | not included) | +-----------------+-----------------+-----------------+-----------------+ | Allied Health | Part of 30 day | One | One | | -- Service | admission | consultation | consultation | | Groups | | fee for each | fee for each | | (Inpatients) | (All-inclusive | AHP for the | AHP for the | | | Fee) | initial contact | initial contact | | | | (SGCON). | (SGCON). | | | | Thereafter one | Thereafter one | | | | treatment fee | treatment fee | | | | per day (SGTRT) | per day (SGTRT) | | | | Where | Where | | | | individual | individual | | | | treatment | treatment | | | | (SGTRT) and | (SGTRT) and | | | | group therapy | group therapy | | | | (SGGRP) are | (SGGRP) are | | | | given on the | given on the | | | | same day, one | same day, one | | | | treatment fee | treatment fee | | | | (SGTRT) will be | (SGTRT) will be | | | | charged. | charged. | +-----------------+-----------------+-----------------+-----------------+ - - **Additional services e.g., transport and other charge entries (assistive devices) must be billed separately where relevant.**  **[4.5 Ward Attender]** **When outpatients are seen in a ward, including patients triaged but not treated, these visits must be recorded on the System.**  **The "Ward Attender" function accommodates the process flow of the hospital when a patient is not seen in an outpatient clinic by a nurse or a doctor, but in a ward. When either one of**  **or** **is selected, the professional fee will be billed according to the "Treated By" selection on the "Account tab".**  **The same rules as for the "Attend Status" of an outpatient visit apply (see p.21).** **The same rules as for the "Attend Charge" of an outpatient visit apply (see p.21). "Services Only" must be selected when no charges are to be raised.**  **[4.6 Cancellation of Visits]** Visits can only be cancelled when the patient was attended, but did not see the doctor in the Outpatient Department, nurse in the nurse driven clinic or the Allied Health Worker. *Please note*: This can be done using the **Attended not Treated** function under Patient Disposal.  **[\ ]** **[4.7 Service Groups]**  Same as Outpatients  - **Consultation** - Must be selected for the first visit to the Allied Health Professional. - **Emergency** - When a patient is treated in the Trauma or Emergency area without an appointment. Emergency Consultation tariff will be charged. (Not selectable for Service groups) - **Group therapy** - Where a group of patients are treated by an Allied Health Worker. - **Home visit** - when full paying patients are visited at their homes, the applicable routine consultation fee, plus additional services and the prescribed kilometre tariff or official vehicles must be charged. This service is free for H0, H1, H2 and H3 patients. - **Post-Operative Visit** -- Must not be selected for service groups. - **Same Day Attend H1** - When an H1 patient attends more than one clinic on the same day and for the same episode, only one visit fee should be charged. No consultation fee will be charged for the other clinics visited. - **Services Only** -- Must not be selected for service groups. - **Treatment** -- This must be selected for subsequent visits to the Allied Health Worker.**\ ** 5. **INPATIENT ADMISSIONS** **[5.1 The Admission Screen]** As soon as the decision to admit a patient has been taken by a clinician, the patient must be registered as an inpatient on the Hospital Information System. A patient will either be: - referred from another hospital for an extended inpatient stay, - booked for a procedure that requires a length of stay, or - the ER doctor will determine that an outpatient must be admitted as an inpatient. large-comic-arrow-pointing-right-0-10773\[1\]*Please note*: The following selections under **Patient Disposal** must be selected:  or Graphical user interface, application Description automatically generated  Information required differs to that required for an outpatient attendance, as indicated on the screen below.  The date and time is of utmost importance as it has a definite impact on how the different categories of patients will be billed. - **H1** patients will be billed for each 30 day period, or part thereof, after admission. - **H2, H3 and Full Paying patients** are billed as per the 12-hour rule. - **Day patients** admitted will be charged the day tariff if they are accommodated in a General ward. This selection applies to the ward the patient will be admitted to as set up for the specific hospital. This selection has no billing implication and differs from the Ward Tab, where different selections will be made.  In this menu the officer must select how, or by whom patient was referred to the hospital. Here the officer must capture the reason why the patient is being admitted to the hospital. This information will not reflect anywhere else.  Since the doctor authorises the admission, the reception officer must record the event that leads up to the admission. This selection will activate the following one. Depending on the previous selection, the Accident Type will either be greyed out or selections can be made regarding the patient's visit to the ER.  If the patient comes from a specific facility, it can be selected here. Depending on the type of facility, the "Transfer From" field will be enabled if the name of the facility is listed. This selection is important when a patient has been referred. **[5.2 Wards]** Patients can be admitted to one of the following wards: - **General Ward** - A general inpatient tariff is charged for services rendered to a patient. - **High Care Unit** - a specially equipped unit where specially trained professional nursing staff are available at all times, supported by medical staff on a standby basis. - **Intensive Care Unit** **(ICU)** - a specially equipped unit which is set up for the intensive care of seriously ill patients and where medical staff and specially trained professional nursing staff are available at all times. - **Specialized ICU** - A Specialized ICU is defined as an Intensive Care Unit, Cardio-Thoracic Intensive Care Unit and Neonatal Intensive Care Unit. The Specialized ICU tariffs shall be billed where patients require specialised critical cardio-thoracic surgery, major vascular surgery, specialized neonatal surgery or neurosurgery involving the brain or spinal cord, as prescribed by a health care professional as per procedures indicated in *[Revenue Notice 11/2018]*. These tariffs are only applicable to Tygerberg, Groote Schuur and Red Cross War Memorial Children's Hospitals. - **Day Ward** - a day care unit; or where such a unit does not exist, a General Ward, where a patient is admitted to for a specific examination or procedure and is discharged before or on 23:00 on the day of admission.  **[5.3 Virtual Wards]** Patients that were admitted to a specialty service after an emergency visit that are still in the ER as they are awaiting a bed or transfer to another hospital. They are admitted to a virtual ward on CLINiCOM and are billed as inpatients. These patients generally lie on trolleys and are in a busy environment but receive full nursing care and meals. **[5.4 Suspension and Suspension Reinstate]** Patients are temporarily suspended from their inpatient stay for the following possible reasons: - Procedure has been postponed by the doctor - When the doctor grants the patient permission to leave and attend to certain matters at home -- this will be dependent on the patient's health condition. Graphical user interface, application Description automatically generated [The process in using these functions are as follows:] 1. The **suspension function** is selected in any of the above scenarios **firstly**. ![large-comic-arrow-pointing-right-0-10773\[1\]](media/image5.png)*Please note:* You may not select **"Suspension Reinstate"** before the **"Suspension"** function. Graphical user interface, application Description automatically generated 2. On patients return to the hospital, the **"Suspension Reinstate"** function should then be used.  **[ClINiCOM / Invoice Example]**  **[5.5 Cancellation of Admissions ]** Admissions can only be cancelled where the inpatient was admitted but did not occupy a bed. When patients are admitted to a bed and the admission must be cancelled afterwards due to hospital constraints, these admissions must not be deleted on the system. The admissions must be suspended with the suspension code SVIMA (AR System) and written off as **Vis Major** cases. *(G42/2002)* **[5.6 Split Invoices]** When the billable account type of a patient changes during an inpatient admission, the Split Invoice function must be used to create two invoices with separate rates for the different periods of the inpatient stay. A split invoice adds a new invoice with different attributes to the same CLINiCOM episode. In the **Split Invoice** function the following billing account types during the inpatient stay of the patient must recorded:  When **Yes** is selected, the date and time will default. A preferred date and time may be captured. The user must populate the Account tab fields with new information for a new invoice to be created.  Excercise 1. Which ward is the most expensive on the tariff schedule? Which is the highest ward level at your hospital? ­­\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ 2. When may a patient be admitted as an inpatient? \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ 3. When may an inpatient admission be cancelled?\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ 4. Explain the Vis Major rule in relation to an admission. \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ **\ ** **6. REFERRALS IN AND BETWEEN HOSPITALS** Referrals that occur in and between hospitals are underwritten by FAR 9/2017. **[6.1 Inpatients]** Where an in-patient is transferred from one state hospital to another, a copy of the admission form must accompany the patient.  The discharge information in the illustration above will filter through from the 1^st^ hospital when the inpatient is admitted at the 2^nd^ hospital, **but only when it is done on the same day**. When the backdated admission is done the following day, the admission officer must capture the information manually. When **H1 Inpatients** are referred from one hospital to another for extended **inpatient stay**, the initial charge will be for 30 days, or until the patient is discharged within the 30 day period. When referred from one hospital to another for **outpatient treatment** only, no outpatient consultation/ treatment must be raised at the second hospital.  When **H2, H3 and Full Paying Inpatients** are referred from one hospital to another for extended **inpatient stay**, the second hospital must charge the accommodation from the following 12- hour period, as well as any services rendered during the initial 12-hour period of the referral. If the patient is transferred back to the referring hospital before the initial 12-hour period has passed, only an account for services (e.g. imaging, laboratory services and theatre), must be raised by the second hospital. When **H2, H3 and Full Paying Inpatients** are referred from one hospital to another for **outpatient treatment** only, the 2^nd^ hospital must raise an account for the appropriate outpatient services. **[6.2 Outpatients]** An **H1 outpatient** referred from one hospital to another for outpatient treatment only, will also be assessed again at the ER of the 2^nd^ hospital; therefore the patient will be liable for both visits. When an **H1 outpatient** is referred from the Primary Healthcare Clinic to the state hospital for X-rays because the facilities are not available, the patient must be charged a consultation fee at the state hospital, which includes the treatment. When an **H2, H3 or Full Paying Patient** is transferred to another state hospital as an outpatient, the 2^nd^ hospital must raise an account for the appropriate outpatient services. **[6.3 Day Patients]** When a day patient is referred from one hospital to another, the second hospital must only raise an account for treatment or services received at the second hospital. When a H2, H3 or full paying day patient is referred from one hospital to another for admission (not referred back to the referring hospital), the 12-hour rule must apply to the second hospital. Only services must be raised for the overlapping 12-hour period and thereafter all applicable charges must be raised. **[6.4 Outpatients to be Admitted]** When a doctor prescribes that outpatients who were treated in the ER (or in other outpatient clinics) must be admitted, they will be liable for the outpatient visit and the inpatient admission. When there are no beds available in the ward that the patients must be transferred to, they must be admitted to the Virtual Ward. When a bed becomes available, patients must be transferred from the Virtual ward to the actual ward they were initially referred to.  Excercise 1. **How must H2, H3 and Full Paying inpatients be billed when transferred from one provincial hospital to another? \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_** 2. **If an H1 inpatient is transferred to a state hospital and is transferred back to the first hospital before the initial 12 hour period has lapsed, how will this patient be billed by the second hospital? \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_** 3. **If a H1 Inpatient is referred from one hospital to another for outpatient treatment only, how will the account be billed by the second hospital?** **\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_** 4. **What documentation is of utmost importance when a patient is referred from one hospital to another?\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_** 5. **Why can an H2 day patient not be billed the same tariff when transferred to another hospital for extended inpatient stay?\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_** **[7. TRANSPORT] *(Revised UPFS User Guide 2011)*** A patient can either be transported from a specific location to a state hospital or from one state hospital to another. Various modes of transport require various billing rules for the different patient categories. All transport services for H0 patients are Free.  **[7.1 Ambulance Transport]** An ambulance is a vehicle specially equipped for the purpose of providing medical care for a patient during the period of transportation to a state hospital. The patient will receive one of 3 levels of care, depending on the services provided and the professional qualifications of the Emergency Care Practitioner. These levels of care are: - Basic Life Support (BLS) - Intermediate Life Support (ILS) - Advanced Life Support (ALS) C:\\Users\\56061013\\AppData\\Local\\Microsoft\\Windows\\Temporary Internet Files\\Content.IE5\\DSSHGGWA\\large-comic-arrow-pointing-right-0-10773\[1\].gif *Please note:* Emergency Care Technician (ECT) is equivalent to ILS The level of care provided, along with the level of the qualification of the EC Practitioner, must be indicated on the Patient Care Report. The levels of qualification are: - Basic Life Support - Intermediate Life Support - Advanced Life Support Additional to Level of Care: - **H0** patients are transported for free. **H1,** **H2, H3, RAF cases and State Department** patients will be charged per 50km, according to the level of care they receive during transport. Accounts for ambulance transport must be raised by the hospital for **H1**, **H2** and **H3** patients, **Road Accident Fund** cases and **State Department** cases. EMS must bill Ambulance Transport for patients who are members of **Medical Schemes**, **IOD** cases or transferred to private hospitals. Copies of such Patient Care Reports must be forwarded to EMS by all state hospitals. Transport for transfers or referrals between state institutions (inter-hospital) of **H0**, **H1**, **H2**, as well as those patients who qualify for Statutory Free Services, are free. **[7.2 Patient Transport (Healthnet) ]** A Patient Transport Vehicle is a vehicle other than an ambulance used to transport patients not requiring medical care during the period of transportation. Hospitals must charge all patients transported by HEALTHNET vehicles, except H0 patients. For all other patient categories, patient transport is charged per 100 km based on the number of district municipalities crossed. Each district is deemed to be 100kms. The officer must capture the actual number of kilometres transported. Inter-hospital transport, whether transfers or referrals of **H0**, **H1**, **H2** and **H3** as well as those patients who qualify for Statutory Free Services will be free. Externally Funded patients and foreigners must pay for patient transport. **[7.3 Air Transport]** This service is rendered by the South African Red Cross Air Mercy Services Trust in accordance with the Service Level Agreement with EMS. Air transport services are performed with fixed-wing aircrafts and rotary aircrafts (helicopter) and are charged as follows with separate tariffs for the two mediums: - H0 patients are Free. - H1 and H2 patients are charged per flying hour by the hospital. - H3 and Full Paying patients are charged per flying hour by Air Mercy. Inter-hospital transport for **H0**, **H1**, **H2**, as well as those patients who qualify for Statutory Free Services are free. **Externally funded** patients, **Foreigners** and **H3** patients must be charged for inter-hospital air transport per flying hour by Air Mercy. **[7.4 Rescue Services]** This service must be charged when special equipment is used to rescue patients involved in motor vehicle accidents. The services performed are recorded on the PCR by the Emergency Care Practitioner and must be charged by the hospital receiving the patient. This charge is in addition to the various levels of care (ambulance transport) provided and is only applicable to RAF cases. The tariff will be charged according to the level of care they receive and per incident.  The diagram below is a summary of the various billing rules for transport. **Transport Matrix** +---------+---------+---------+---------+---------+---------+---------+ | Patient | Patient | Inter | Ambulan | Inter | Air | Inter | | Categor | Transpo | Hospita | ce | Hospita | Transpo | Hospita | | y | rt | l | | l | rt | l | | | | Healthn | | Ambulan | | Air | | | Healthn | et | | ce | (Fixed | Transpo | | | et | | | | wing or | rt | | | | | | | Helicop | | | | | | | | ter) | (Fixed | | | | | | | | wing or | | | | | | | | Helicop | | | | | | | | ter) | +=========+=========+=========+=========+=========+=========+=========+ | H0 | Free | Free | Free | Free | Free | Free | +---------+---------+---------+---------+---------+---------+---------+ | H1 | Tariff | Free | Level | Free | Tariff | Free | | | per | | of | | per | | | | 100km | | Care/50 | | Flying | | | | | | km | | hour | | +---------+---------+---------+---------+---------+---------+---------+ | H2 | Tariff | Free | Level | Free | Tariff | Free | | | per | | of | | per | | | | 100km | | Care/50 | | Flying | | | | | | km | | hour | | +---------+---------+---------+---------+---------+---------+---------+ | H3 | Tariff | Free | Level | Level | Tariff | Tariff | | | per | | of | of | per | per | | | 100km | | Care/50 | Care/50 | Flying | Flying | | | | | km | km | hour | hour | | | | | | | | | | | | | | | (Air | (Air | | | | | | | Mercy | Mercy | | | | | | | to | to | | | | | | | bill) | bill) | +---------+---------+---------+---------+---------+---------+---------+ | Full | Tariff | Tariff | Level | Level | Tariff | Tariff | | Paying | per | per | of | of | per | per | | | 100km | 100km | Care/50 | Care/50 | Flying | Flying | | | | | km | km | hour | hour | | | | EMS to | | | | | | | | bill | EMS to | EMS to | (Air | (Air | | | | IOD and | bill | bill | Mercy | Mercy | | | | Medical | IOD and | IOD and | to | to | | | | Scheme | Medical | Medical | bill) | bill) | | | | cases | Scheme | Scheme | **(Exce | **(Exce | | | | | cases | cases | pt | pt | | | | | | | RAF | RAF | | | | | | | cases)* | cases)* | | | | | | | * | * | +---------+---------+---------+---------+---------+---------+---------+ | Stat | Tariff | Free | Level | Free | Tariff | Free, | | Free | per | | of | | per | exclude | | Service | 100km | | Care/50 | | Flying | s | | s | | | km | | hour | H3 & | | | | | | | | Full | | (Except | | | | | | Paying | | TOP) | | | | | | | +---------+---------+---------+---------+---------+---------+---------+ **EMS Charge Matrix** **Level of Care on PCR:** **EMS Practitioner:** **EMS Practitioner:** **EMS Charge:** --------------------------- ----------------------- ----------------------- --------------------------- **Green** ILS BLS Basic Life Support **Green** BLS ALS Basic Life Support **Green** BLS BLS Basic Life Support **Yellow/Orange** BLS BLS Basic Life Support **Yellow/Orange** ILS ILS Intermediate Life Support **Yellow/Orange** BLS ILS Intermediate Life Support **Yellow/Orange** BLS ALS Intermediate Life Support **Yellow/Orange** ALS ALS Intermediate Life Support **Red** BLS BLS Basic Life Support **Red** ILS ILS Intermediate Life Support **Red** BLS ILS Intermediate Life Support **Red** BLS ALS Advance Life Support **Red** ILS ALS Advance Life Support **Red** ALS ALS Advance Life Support **Specified** Unspecified Unspecified Basic Life Support **Unspecified** Specified Specified Basic Life Support Exercise 1. **Which three factors must be considered to determine the tariff to be charged for ambulance transport?\_\_\_\_\_\_\_\_\_\_\_** 2. **What must an H1 patient be charged who received ILS by EC Practitioners with ALS and BLS qualifications respectively? \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_** 3. **What must an H2 patient be charged who received ALS by EC Practitioners with ILS and BLS qualifications respectively?\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_** 4. **Which categories of patients must not be charged for Patient Transport?\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_** **[\ ]**  Selections are made on the "Account" Tab in CLINiCOM to give effect to relevant policies regarding specific admissions and attendances registered at a provincial hospital. All selections are compulsory and the reception officer will not be allowed to proceed without completing it. Various rules or parameters have also been built into the system to ensure that certain selections made, will not be in conflict with following ones.  The illustration above shows the message that the system will show when such conflicting selections are made. **[8.1 Statutory Free Services]** There are certain circumstances in which patients are exempted from paying for health services, **irrespective of their classification as full paying or subsidized patients**. These circumstances have a statutory basis and apply only to the episode of care directly related to the circumstances under which the patient has qualified for free services. The patient status in terms of the conditions set out in *Annexure C - DISEASES/CONDITIONS/ PATIENTS THAT ARE TREATED FREE OF CHARGE*, must be confirmed by a clinician in order to receive these services for free. This is not the default classification for a patient attending a public hospital. Statutory Free Services are as follows: **8.1.1 Babies for Adoption** This service is free for babies from birth until the adoption has been completed and no charges will be raised.  The system will automatically default the rest of the Account Tab to and will not allow the completion of the debtor details. **8.1.2 Anti-Retroviral Services** *(Annexure C Section 7.1.11)* ARV Services on an outpatient basis are normally provided at Primary Health Care (PHC) level. However, due to the influx of patients, secondary and tertiary hospitals have been used as interim ARV sites where the services were needed. In this instance H0, H1, H2 and H3 patients receiving ARV treatment at secondary and tertiary institutions will not be billed.  **8.1.3 Committed Children** *(Annexure C Section 18.1)* Healthcare services to children who, in terms of Section 15 and 16 of the Child Care Act, 1983 (Act No. 74 of 1983) are committed to the care of a children\'s home, industrial school, foster parents/guardians, or a place of safety is free. Such children are placed in foster care by a court and a certificate of authority must be produced. Children must be under 18 years old, but permission can be given to a patient between 18 and 21 years old who is still in high school. **8.1.4 Dental Examinations** This selection is only available to Tygerberg/Mitchell's Plain Oral Health Centres. In the case of an Oral Health training hospital where shortages exist in certain disciplines for practical clinical training, patients may be treated free of charge in terms of the procedure on authority granted by the head of the institution. The cost of the laboratory items and other fees must be recovered. The patient as well as the specific treatment code/s and the student rendering the service must be identified in advance. An authorisation form signed by the head of the institution specifying the specific training need and oral procedures to be performed free must be filed centrally and a copy placed in the patient's folder for audit purposes. The patient must give written consent in respect of the procedure which is to be performed.  **8.1.5 Donors** *(Annexure C Section 3.1.6)* A person who donates an organ for transplant purposes at a state hospital, or who dies in the hospital and whose family have agreed to the donation of an organ, or organs. Any South African donor, as well as foreigners who will be assessed according to their income based on their purposes for entering South Africa; must be treated free of charge since the moment a bed is occupied for transplant purposes only where the receiving party is a South African citizen. These services will include compatibility tests where blood, bone marrow, organs, etc. will be donated on an outpatient basis. Members of medical schemes must also receive this service free of charge.  The Patient number of the patient receiving the transplant must be captured in CLINiCOM to link the free service to the patient. If the officer does not have the patient number at hand, a search can be performed. **8.1.6 Admissions for Examination Purposes** A person who may be admitted to an **academic hospital** for the specific purpose of providing clinical material for professional examinations (includes accommodation and medication but excludes other services or treatment not related thereto). An authorisation form signed by the head of the institution specifying the specific training need and oral procedures to be performed for free must be filed centrally and a copy placed in the patient's folder for audit purposes. The patient must give written consent in respect of the procedure which is to be performed. **8.1.7 Family planning** *(Annexure C Section 1.1.5)* Free healthcare services under family planning include: - Treatment given at a designated family planning clinic given on an outpatient basis e.g. oral contraception, intramuscular (injection), condoms, intra uterine device & other devices. - In-patient services under a family planning programme for the purposes of a sterilisation/ vasectomy operation. - A maternity patient from the day that a post-partum sterilisation is performed as part of a family planning programme. (The decision should be made in advance and in conjunction with counselling.) - patients with a private practitioner - externally funded patients - patients utilising the revenue generation project facilities. - A maternity patient after a failed family planning programme sterilisation procedure in a state hospital. Ante natal visits, complications during pregnancy & delivery, laboratory services, medication etc. The aforementioned is only applicable to a state hospital where the initial sterilisation/vasectomy was performed. - A patient who visits a clinic or hospital on the recommendation of family planning staff or who is referred from a Primary Healthcare Clinic for the specific purpose of being sterilised, even if such a procedure is performed by a private doctor during the confinement period in a state hospital. Transport to such a clinic or hospital is free, as well as treatment for any medical complications arising from the sterilisation procedure. - Scheduled sperm counts after a vasectomy which was performed at a state institution as part of a family planning program.  **8.1.8 School Children** *(Annexure C Section 17)* The treatment of school children who are classified as H0 and H1-patients (according to their parents/guardians' income) and who are referred with a letter of authority from the school nursing services for oral health treatment is free. The authorisation letter is compulsory and can only be used for the services that must be performed on the date of services rendered. The date of the letter must be captured in the authorization field. **8.1.9 Free Services for Hospital Personnel** *(Annexure C Section 4)* These include staff and voluntary workers of the Department of Health requiring the following services: - **Injury-on-duty cases** - **Medical examinations** - Compulsory routine examinations of personnel. - Immunisation and measures to combat infectious diseases. - Examinations to verify sick leave and medical boarding. - Examinations and blood tests of staff members suspected of being under the influence of alcohol while on duty. - Free outpatient services as determined from time to time by the Health Management Committee (HMC) may be rendered in specific cases to personnel, voluntary workers and applicants in **staff sick bays** of state hospitals, such as **minor ailments** which require straightforward treatment and medication for a period not longer than 24 hours. **8.1.10 Immunisation** *(Annexure C Section 6)* Outpatients who volunteer for immunisations and other measures to combat notifiable infectious diseases (excluding immunisations & other services for foreign travel) receive services free of charge.  **8.1.11 Infectious/Notifiable Diseases** *(Annexure C Section 7)* The treatment of the following infectious, formidable and/or suspected notifiable diseases is free when these diseases are treated as the primary diagnosis and not co-morbidity (secondary diagnosis). - Venereal diseases (excluding complications) -- free treatment will only be on an outpatient basis and including the following: - Syphilis - Gonorrhoea - Cancroids - LGV (lympho granuloma venereum) - Non-specific Urethritis - Venereal warts - Granuloma inguinal - Ulcus molle - Herpes Genitalis - All forms of Tuberculosis - Leprosy - Cholera - Diphtheria - Plague - Typhoid and paratyphoid - Haemorrhagic fevers - Meningococcal meningitis - Aids - the initial diagnostic procedures and attendant laboratory services are free if patients specifically ask for the HIV test to be done. - ARV medication to H0, H1, H2 and H3 patients at a designated ARV Clinic will not be billed - Cerebral Palsy patients must be treated free at any provincial hospital; and includes all services as required by the patient, as well as Healthnet and ambulance transport. Cerebral Palsy patients must also be treated free at NGO/PBO's that are contracted by the department. Externally Funded Patients are excluded from free services; however, patients will not be held liable for any shortfall in funder payments. C:\\Users\\56061013\\AppData\\Local\\Microsoft\\Windows\\Temporary Internet Files\\Content.IE5\\8BWM87QY\\disse\[1\].png **8.1.12 Oral Health Services** *(Annexure C Section 12)* Oral health services must be given for free to scholars who are classified as H0 and H1 patients with valid school authorisation cards when referred by school nursing services to **Oral Health Centres**. Free services also include screening, preventive services and promotional services rendered at schools. - Where a patient has to return within a period of six months for incomplete services performed by a dental student, the supervisory clinician must determine whether it is to be billed or whether it is part of the initial service performed. ![C:\\Users\\56061013\\AppData\\Local\\Microsoft\\Windows\\Temporary Internet Files\\Content.IE5\\DSSHGGWA\\large-comic-arrow-pointing-right-0-10773\[1\].gif](media/image5.png) *Please note:* This selection is only applicable to the Oral Health Centres. **\ ** **8.1.13 Pregnant Women** *(Annexure C Section 20)* Free medical services must be rendered to pregnant women in the H0, H1, H2 and H3 patient categories (excluding Full Paying patients) for the period commencing from the time the pregnancy is diagnosed to forty-two days after the pregnancy has terminated; or if a complication has developed as a result of the pregnancy until the patient has been cured or the conditions as result of the complication has stabilised. Medical services exclude the treatment of conditions that are not specifically related to the pregnancy, except for: - At an academic or secondary hospital in the obstetric / gynaecological department where a pregnant woman who suffers from a chronic disease is treated, the service is regarded as pregnancy related and is therefore free for H1, H2 and H3 patients. - At a district hospital, where an obstetric department is not well defined, and where a pregnant woman who suffers from a chronic disease is treated at the emergency area of the district hospital, the service is regarded as pregnancy related and is therefore free for H1, H2 and H3 patients.  **8.1.14 Mentally Ill Patients*