Newsletter: August 2018
Background introduction to The Hospital Dietitians Interest Group (HDIG)
HDIG was formed in 2010 for the purpose of advocating on behalf of dietitians working in the hospital environment. HDIG focusses on interacting with relevant stakeholders in the healthcare sector to protect and promote the interests of hospital-based dietitians and raise awareness of the important role of the dietitian in the clinical management of hospitalised patients. HDIG also aims to enhance awareness of the scope of practice of the hospital dietitian and ensure that this key professional practice area is well-positioned through the current changes occurring in the South African healthcare structure and enjoys an enhanced career profile in future.
In this newsletter, we would like to highlight some of the issues affecting hospital dietitians that HDIG has been working on and participating in as a voice for our profession.
Dietitians tariffs/billing project
Part of our mandate to protect the specialised scope of practice of the hospital dietitian is to ensure that dietitians are able to maximise their earning potential and to receive the same level of reimbursement etiquette from funders as other health professions.
This task involves two main aspects. Firstly, ongoing engagement with medical aids to develop deeper insight by funders into the professional clinical services being provided by dietitians to patients in hospital care, and facilitating improved and more supportive pre-authorisation and authorisation pathways. Secondly, the establishment of a standardised tariff structure for the reimbursement of dietetic services that could be implemented across the entire funder market.
Over the course of a 2-year engagement with Heathman, a healthcare consultancy with extensive experience in advisory input on various types of tariff systems, the current updated billing system for dietitians has now been finalised. Under guidance by Heathman, this billing structure has been carefully adapted based on various factors unique to the South African setting and to dietetic practice, and includes the following important changes:
- The inclusion of the option to bill for time spent on medical nutrition therapy planning (non-face time)
- The incorporation of modifier codes to provide better descriptions of the service being rendered. New inclusions include the use of a modifier for compiling patient motivations and feedback reports for funders.
- The inclusion of a code for home visits
The final version of the revised tariff codes and rules can be viewed here (ADSA Revised Coding Structure).
What happens next?
Currently, no funder has accepted this billing schedule, although HDIG is in the process of negotiating uptake by medical schemes. One of the critical gaps is that practice cost data is needed from dietitians running private practices in South Africa in order to determine and adjust the Relative Value Unit (RVU). In order to obtain this data, we are currently running a practice cost study, which is the very first in South Africa to identify the global costs involved in running a dietetic practice. This data is critical for correctly aligning our RVUs and selling the tariff system to funders.
PLEASE assist us by participating in this audit to support the initiative of implementing standardised billing, which will benefit our entire profession. Use the link (Practice Cost survey) here to include your practice cost data in the national costing survey. Note that your information is protected.
What can I do?
In addition to submitting your practice cost data, you are encouraged to utilise the revised billing schedule when submitting claims to funders, including the use of the new modifier codes. This will create consistent pressure on funders to implement and also contributes to establishing a profession-wide billing pattern and builds funder awareness of the services being offered by dietitians in hospital practice.
Footnote: Some practices have asked about the correct code to be used when billing for Discovery Vitality assessments. Note that the Vitality Assessment code has been discontinued. Instead, the Vitality programme covers the cost of an ordinary dietetic consult which meets the aims of the Vitality programme. For Vitality Assessments, bill for an ordinary consult according to the Discovery tariff schedule.
Dietitians on the Medical Scheme radar for fraudulent practices
HDIG is contacted frequently by dietitians for assistance with how to deal with fraud investigations by funders. It has become apparent that dietitians have been flagged as a profession under the spotlight by funders for misleading or fraudulent billing. Unfortunately, there have been isolated incidents of genuine fraud and unjustified over-billing committed by dietitians in private practice.
Dietitians are encouraged to be familiar with the codes of conduct and ethical practice as regulated by the HPCSA, and to uphold conscientious and ethical billing practices. However, part of the interest of funders in dietetic claims may be related to the lack of insight by schemes as to the role of the hospital-based dietitian inpatient care. HDIG supports ethical and rational reimbursement practices through its awareness-building interactions with medical schemes on behalf of practitioners as well as through the implementation of the revised billing schedule.
The Council for Medical Schemes Prescribed Minimum Benefits Review and Definition Project
Hospital dietitians may be interested to know that the Council for Medical Schemes (CMS) is currently busy with a significant review and overhaul of the defined benefits for Prescribed Minimum Benefit (PMB) conditions as part of NHI preparation. PMBs are regulated entitlements that medical schemes are obliged to cover. For the first time, the South African regulatory framework has specified medical nutrition therapy entitlements for a number of PMB conditions. Two CMS documents have been published in the last 15 months, which specify the nutrition benefits to which all patients are entitled.
Firstly, patients with early and late-stage gastrointestinal cancers (oesophageal, gastric, pancreatic and colorectal cancers) who are inactive treatment are now specifically entitled to receive the following medical nutrition therapy benefits:
- Pre-operative carbohydrate loading
- Peri-operative nutrition management, which could include: Pre-operative nutrition optimization and/or Peri-operative nutrition support
- Post-operative nutrition management
- Nutrition management during ongoing medical interventions (including chemo- and/or radiotherapy).
Such patients are entitled to receive commercial nutrition products via the oral or enteral route (ONS or full enteral feeding) along with a specified number of dietetic consults, which depends on the nutritional status of the patient and the stage of disease. This benefit also allows for the use of ONS or enteral feeding in the home setting with coverage of commercial product and all associated consumable items. For a full outline of the details of this nutrition benefit, see section 10 of the CMS regulation (link CMS Best Supportive Care Nutrition Benefit ).
Secondly, medical nutrition benefits have been defined for a large number of clinical conditions where patients are not curable and are in a palliative care journey. These conditions include all forms of Cancer when curative therapy has ended or is not an option (this includes the GIT cancers named in the above paragraph); HIV/AIDS and TB; Progressive Neurological Diseases; Chronic Kidney Disease; Chronic Heart Disease; Chronic Liver Disease and Chronic Respiratory Disease when part of a palliative care process.
Note that the PMB, in this case, is Palliative Care, rather than the underlying disease diagnosis. Such patients are entitled to receive commercial nutrition products mainly via the oral route (ONS), but some categories of patients are also entitled to enteral nutrition support including in the home setting. Nutrition support also includes a specified number of consultations with a dietitian.
Nutrition benefits for this PMB category are divided into two phases: a) palliative care where nutrition benefits are substantial, and b) end-of-life care where nutrition benefits are minimal and focussed on comfort. For a full outline of the details of this nutrition benefit, see CMS regulation (CMS Palliative Care Nutrition Benefit).
HDIG will continue to participate in advising on the relevant nutrition benefits as further PMB conditions are reviewed and defined.
Tips on medical aid motivations
Many dietitians have reported inconsistent claims coverage when submitting motivations for various of nutrition support and associated professional services, even for the abovementioned PMB conditions. Here are a few tips on how to address medical scheme rejections of claims from the dietitian:
- Incorrect ICD-10 coding. This is the most common reason for claims rejection. The primary ICD-10 code for a nutrition support claim may not be the diagnosis code. For example, for all palliative care patients who are covered by the CMS Palliative Care regulation (see above), the primary code should be Palliative Care (Z51.5) and the diagnosis code is the secondary code. Similarly, for patients requiring PEG feeds at home for dysphagia, the primary code should be Dysphagia (R13) and the diagnosis code secondary. Other problems with claims submissions are where the primary ICD-10 code used by different members of the multi-disciplinary team is inconsistent or misaligned.
- Application of scheme algorithms. Medical schemes are allowed to interpret the PMB regulations according to their own internal policies, set eligibility criteria and use formularies. Sometimes these are inappropriately applied to legitimate claims. There are certain schemes whose policy is to reject claims on the first submission to test the sincerity or urgency of the coverage need.
- Content of motivation letters. When motivating for nutrition support, don’t include information which is highly subjective or open to interpretation or provide excessive additional clinical notes. Stick to a concise and evidence-based rationale for your motivation, ensure that your prescription and requirement calculation are aligned, and provide the specific indication for a particular product being requested.
- Incorrect funding channel. PMB fund pool is usually a different pool than case-by-case or Ex gratia PMB claims should be automatically covered if correctly formulated. If you are motivating for a non-PMB condition, use the Ex Gratia process. This process goes straight to a clinical review committee and use of this channel, when appropriate, places pressure on the medical scheme to establish internal clinical protocols for nutrition coverage.
What can I do?
Dietitians have an important role in communally applying pressure on funders to uphold legitimate claims and learn more about appropriate nutrition claim patterns. Please continue to support the profession by submitting professionally formulated motivations, refusing to accept the rejection of genuine claims, appealing non-coverage or claims denials and adding to the credible clinical practice pattern when viewed by funders as a national phenomenon.
The CMS also has a complaints procedure which patients can follow when justifiable claims are denied. See CMS Complaints on how to submit a complaint. The CMS complaints unit then makes an evaluation as to the legitimacy of the claim and intervenes with the medical scheme on behalf of the patient.
We are aware of the huge difficulties surrounding claims for WCA/COIDA cases. This is because dietitians are not currently listed as a professional group entitled to claim against the WCA. There is an ongoing legal process around and unpaid claims for dietitians are part of a number of disputed claims which will be debated with the Commissioner pertaining to a court order to do so. This will take place on 28 August 2018.
If the outcome is positive, dietitians will be listed in the Government Gazette as professionals who can be reimbursed for WCA claims. In the meantime, dietitians are encouraged to consult and invoice WCA patients. This creates a submission profile so that when the Commissioner instructs that dietitians must be paid, claims have already been submitted. If you are unsure as to the process of how to submit WCA claims, contact Inge or Berna at the HDIG (info@HDIG.co.za).
HDIG is looking to offer a practical workshop covering the topics of medical aid motivations and claims and ethical practice and billing conduct. Please help us with the planning by registering your interest in such a workshop by clicking the link here to answer the 2-minute survey (HDIG workshop survey).
You received this newsletter via the ADSA PPD email contact list. HDIG is establishing a database of dietitians in hospital practice in order to keep everyone in the loop as to important matters affecting our practice, and build a critical mass of professional support to allow us to better represent the needs and interests of our profession. Please visit our website (https://www.hdig.co.za) and register to receive HDIG communication and important newsflashes directly to your mailbox. You can also keep an eye on news and events via our web portal.