Billing guide for specialists and surgeons in South Africa

In-hospital vs rooms billing

Specialists bill in two settings with different rules. Rooms consultations and procedures are billed by your practice and paid from the patient’s day-to-day benefits or savings, depending on the option. In-hospital services are billed by your practice separately from the hospital’s account, usually against the patient’s hospital benefit and an authorisation.

• Bill the correct place of service. The same procedure can pay differently in rooms and in hospital.
• Check which benefit an in-rooms procedure is paid from before the patient books.
• Keep hospital accounts linked to the admission and the authorisation number.

Procedure and tariff coding with ICD-10 linkage

Every line on a claim needs a procedure or tariff code and an ICD-10 diagnosis code that justifies it. Schemes check that the codes are consistent with each other.

• Code to the highest level of detail the ICD-10 code allows; unspecific codes are often queried.
• Injury codes need an external cause code as well.
• Link each procedure to the diagnosis it treats, not only to the main diagnosis.
• Apply modifiers correctly for multiple procedures, assistants and time-based services. Missed modifiers lose income and wrong ones cause rejections.
• Base codes on the operation notes, and keep theatre notes complete enough to support what was billed.

Pre-authorisation

Most hospital admissions and many procedures need authorisation from the scheme before they happen. The authorisation covers specific codes, dates and sometimes the number of days.

• Get the authorisation number and quote it on the account.
• If the procedure changes in theatre, update the authorisation. Billing codes that weren’t authorised are a common reason for short payment.
• Keep proof of authorisation with the patient record.

Scheme rules and PMBs

Each scheme and option has its own rules, tariffs, networks and exclusions. Prescribed Minimum Benefits (PMBs) are conditions schemes must cover under the Medical Schemes Act, subject to rules such as designated service providers (DSPs), formularies and treatment protocols.

• Use the correct PMB ICD-10 code. A PMB that isn’t coded as one is often paid from the wrong benefit or not at all.
• Check whether the patient must use a DSP or network for full cover.
• Follow up claims that were paid from savings or rejected when they should have been treated as PMBs.

Assistant and anaesthetist accounts

Surgical assistants and anaesthetists bill their own accounts under their own practice numbers. Anaesthetic accounts are generally based on the procedure and time units; assistant fees are linked to the procedure performed.

• Share accurate procedure codes and theatre times with the other practices on the case.
• Make sure assistant and anaesthetic codes match the surgeon’s codes and the authorisation.
• Patients receive several accounts for one operation; explaining this before the procedure prevents confusion and queries.

The gap and co-payment conversation

When your fee is higher than what the scheme pays, or the option has a co-payment, the patient pays the difference. Patients should hear about this before the procedure, not after.

• Give the patient a written quote with codes, so they can check cover with their scheme.
• Explain co-payments, network rules and any shortfall in plain language. This is informed financial consent.
• Patients with gap cover can claim the shortfall from their insurer according to their policy, which needs your account and the scheme’s statement.

Common rejection causes and how to prevent them

Debtor follow-up

Submitting a claim is only half the job. What matters is what is actually collected.

• Reconcile every scheme remittance against what was billed, and query short payments.
• Deal with rejections every day instead of letting them pile up.
• Send patients clear statements for their portion and follow up consistently.
• Review an age analysis of your debtors every month, so older accounts get attention before they become hard to collect.

Switching or opening a practice

Opening a practice means sorting out your HPCSA registration, a practice number, billing software, the tariffs you will charge and how patients will be billed, before the first claim. Switching bureaus means handing over open claims and debtors without losing track of them.

Forte advises on and sets up new practices, and when you switch, runs alongside your old bureau for an agreed period while older claims are finished off. See how switching works.

What a billing review covers

A free billing review is a no-obligation conversation and a look at how your practice bills today. It covers:

• How claims are coded and submitted, in hospital and in rooms
• Your authorisation process and where claims are rejected
• How remittances are reconciled and debtors followed up
• Your reports, and what you can see about your collections
• A quote for your practice: a percentage of what is actually collected, with no hidden costs, no setup fee and no annual increases

Please don’t send patient information through the website.