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1. Claims Origination 2. Claims Determination 3. Claims Litigation 4. Claims Finalisation
Claims Processing Value Chain
1.1. Hospital service centres
1.1. Community service centres
1.2. Document management *
1.3. Registration, validation & verification
1.4. Mobile RAF
2.1. Medical
2.2. Represented claims
2.3. Direct claims
3.1. Summons administration
3.3. Internal law department (ILD)
3.4. Magistrate, high & district court litigation
3.5. Panel attorney management
4.1. Capital payment
4.2. Legal cost validation
4.3. Legal cost payment
4.4. Writs payment
3.6. Judgement monitoring
4.5. Claims file closure
5. Post Claims Settlement
5.1. Post claims management
1.5. Merits
3.2. Writs management
2.4. Supplier claims
Version 14, 07 June 2013* Report to Correspondence Manager
Symbols and Abbreviations
On page reference
Off page reference
Action
Process
Decision
Symbols Abbreviations
· AMA - American Medical Association· BI - Body Identification· BIF - Banking Indemnity Form· CAFS – Central Archiving Filing System· CC - Compensation Commissioner· CLS - Legal and Compliance· CO - Claims Officer· COO - Chief Operations Officer· CSC - Customer Service Consultant/Centre· DM - Document Management· DOA - Date of Accident· DoB - Date of Birth· EA - Expenditure Authorisation· EIL - Employer Individually Liable· ES - Executive Summary· FCM - Field Case Manager· GD- General Damages· GM - General Manager· HCM - Hospital Case Manager· HPCSA - Health Professions Council Of South
Africa· HSC - Hospital Service Consultant/Centre· ICT - Information Communication
Technology· ID - Identity Document· ILD - Internal Law Department· IT - Information Technology· LCO - Legal Cost Officer· LoE - Loss of Earnings
· LoS - Loss of Support· MMI - Maximum Medical Improvement· MVA - Motor Vehicle Accident· NB - Nota Bene (Important)· OAR - Official Accident Report· PA - Panel Attorney· POP - Patient Outreach Program· RAF - Road Accident Fund· RAF 1 - Road Accident Fund Form 1· RAF 2 - Road Accident Fund Form 2· RAF 3 - Road Accident Fund Form 3· RAF 4 - Road Accident Fund Form 4· RAF 5 - Road Accident Fund Form 5· RSA - Republic of South Africa· SAPS - South African Police Service· SMR - Statutory Medical Report· SMS – Summons Management System· SOP - Standard Operating Procedure· U number - Undertakings Number· U system - Undertakings System· UBC - Unabridged Birth Certificate· UO - Undertakings Officer· V&V - Validation and Verification· WCC - Workmen's Compensation Commission
System intervention
1. Claims Origination 2. Claims Determination 3. Claims Litigation 4. Claims Finalisation
Claims Processing Value Chain
1.1. Hospital service centres
1.1. Community service centres
1.2. Document management
1.3. Registration, validation & verification
1.4. Mobile RAF
2.1. Medical
2.2. Represented claims
2.3. Direct claims
3.1. Summons administration
3.3. Internal law department (ILD)
3.4. Magistrate, high & district court litigation
3.5. Panel attorney management
4.1. Capital payment
4.2. Legal cost validation
4.3. Legal cost payment
4.4. Writs payment
3.6. Judgement monitoring
4.5. Claims file closure
5. Post Claims Settlement
5.1. Post claims management
1.5. Merits
3.2. Writs management
2.4. Supplier claims
5.1.1. Post claims management (Part 1 of 4)C
laim
s D
eter
min
atio
ns
Dep
artm
ent
Claims Officer
Claims Officer
Claims Officer
Claims Officer
Claims officer
Claims Officer
Claims Officer Claims officer
Claims officer
Is claimant still in hospital?
5.1.1.1. Hospital case management
5.1.1.2. Field case
management
Send certificate for senior review
Does senior approve the value
of the undertaking?
Issue undertaking and notify claimant
Revise certificate
Yes
B
Appoint a field case manager (FCM)
Appoint a hospital case manager
(HCM)
Is the Fund liable?
Does a new undertaking need
to be issued?
D
A
A
A
Receive undertaking request or retrieve
dormant undertaking
No
Yes
No
Yes
No
Draft undertaking certificate
Create File Copies with all
information required for undertakings
Yes
B
C
L
Direct or Represented
claimant?Direct
Consult claimants attorney prior to
issuing undertaking
RepresentedNo
D
5.1.1. Post claims management (Part 2 of 4)
Undertakings senior
Admin Assistant
Admin Assistant
Admin Assistant
Undertakings senior
Undertakings officer
Undertaking officer
Undertakings officer
Admin Assistant
Admin Assistant
Retrieve file
Is undertaking registered on U
system and does it have an excel file?
Check if undertaking is
registered on U system and if it has an excel file
Register undertaking on U
system
Is the file located? Yes
Create dummy file
Locate the claim file by checking on system who last had the file
and request accordingly
Receive undertakings
certificate from claims
department
No
DYes
No
DAllocate
Undertaking to undertakings officer
Is the claim a pre-authorisation
request or medical invoice?
Make initial assessment of
undertaking and create excel file
Capture invoice details on excel file
5.1.1.3. Determine clinical appropriateness and correctness
Invoice appropriate and
correct?
Is amount within mandate?
L
No No
Yes
E
E
Approve authorisation/
invoice
Yes
C
H
F
FL
No
Receive report from HCM & FCM indicating the
condition of the claimant
Check:1. If the claim is for the claimant2.After the date of inception3. Accident related 4. Reasonable5. Tariffs if applicable 6. Duplicate payment
5.1.1. Post claims management (Part 3 of 4)
Undertakings officer
Undertakings senior
Undertakings officer
Undertakings senior Manager
1.1.4. Prepare payment list
Notify claimant and service provider
Is there another payment request?
Yes
No
Print excel spreadsheet and attach invoice for
senior review
Approve authorisation/
invoice
G
Does the approval require
escalation
G
No
Escalate to relevant level for approval
Yes G
Approve excel spreadsheet and
invoice according to mandate
H
F
I
5.1.1. Post claims management (Part 4 of 4)
Undertakings officer
Undertakings officer
Undertakings Officer
Undertakings Officer
Undertakings Officer
Undertakings Officer
Undertakings Officer
Capital payment officer
Capital payment officer
LReject invoice/pre-
authorisation request
Notify claimant and service provider
Is the practice number
available?
Compare practice number to practice
numbers on the service provider table
Compare service provider details to
RAF accredited table
Is the service provider
accredited with the RAF?
J
K
Is service provider
registered?
Verify legal liability of valid service
provider
Send invalid service provider details for
senior/forensics review
Yes
No
J
K
Yes
No
Yes
No
Diarise and follow up in a week
I
Initiate payment of undertaking
EndValidate Invoice and check for duplicate
payments
End
I
5.1.1.1. Hospital case management (POP)
Hospital case manager
Hospital case manager
Hospital case manager
Hospital case manager
Hospital case manager
Hospital case manager
Hospital case manager
Hospital case manager
Hospital case manager
Hospital case manager
Hospital case manager
Hospital case manager Hospital case manager
Advise HSC on which claims are
serious and require undertakings
End
A
Visit the patient in the ward
Assess claimant situation, compile
detailed report
Educate claimant on undertaking
Compile detailed injury report
5.1.1.2.1. Plan treatment
Attach detailed report to claim to support an interim undertaking to
be issued
A
·Extent of RAF support and commitments·RAF liabilities and RAF policies·Pre-existing co-morbidities·Accident relatedness
·Communicate plan to all concerned·Pre-authorize procedures·Advocate for services·Procure services·Coordinate services·Train caregiver(if necessary)·Formulate report
Assess and implement
treatment planMonitor the case
·Status of the client·Continuous education on care·Equipment allocated to client
Revisit the case and determine goal accomplishment, timeliness client, client
satisfaction andcost – benefit analysis
Assess case and discharge from case management when
satisfied
·Client declines or no longer requires service·Goals have been achieved·No further service required·Client transferred to another case manager·Demise of client
Continue communicating with
client, caregiver, family and service provider
Discharge plan and communicate plan
to field case manager
B
B
Disengagement from client in the event:·Client declines or no longer requires service·Goals have been achieved·No further service required·Client transferred to another case manager·Demise of client
5.1.1.2. Field case management (POP)
Field case manager
Field case manager
Field case manager
Field case manager
Field case manager
Field case manager
Field case manager
Field case manager
Field case manager
Field case manager
Field case manager Field case manager
Field case manager
Field case manager
Review claimant history, check HCM
profile on SharePoint and on
file
Trace claimant
Schedule claimant home visit
Assess claimant situation, compile
detailed report
Educate claimant on undertaking
Compile detailed injury report
5.1.1.2.1. Plan treatment
A
Appoint caregiverA
B
Assess and implement
treatment plan
Can you contact the claimant
telephonically?Yes
No
Is the claimant dead?
End YesUpdate file and
send to the original undertakings officer
No
Are contact details
available?Yes
C
No
C
Send an SMS to the claimant and follow
up in 2 daysD
D
·Communicate plan to all (caregiver, service provider ,claims handler)·Pre-authorize procedures·Advocate for services·Procure services·Coordinate services·Formulate report
Monitor the treatment plan
physically or telephonically
·Status of the client·Caregiver(continuous education on care)·Assistive devices/equipment allocated to client e.g. check seating in wheelchair or if cushion is still proper.
Revisit the case and determine goal accomplishment, timeliness client, client
satisfaction andcost – benefit analysis
End
Caregiver required?
No
B
Yes
Assess case and discharge from case management when
satisfied
·Client declines or no longer requires service·Goals have been achieved·No further service required·Client transferred to another case manager·Demise of client
5.1.1.2.1. Plan treatment plan (POP)
Hospital/Field case manager
Hospital/Field case manager
Hospital/Field case manager
Hospital/Field case manager
Assess clinical information
available
Clinical information adequate?
Obtain adequate clinical information
Create appropriate treatment plan
EndYes
No
Create clinical case record
· Identify medical interventions necessary
· Identify related needs of client & family
· Identify related needs of client & caregiver
· Identify relevant service providers for client
· State recommended interventions
· Identify barriers· Develop contingency
plan· Set target dates· Get buy-in of plan to
client & family· Get consent from all
concerned(client, caregiver & family)
·Comprehensive emergency·Psychological·Rehabilitation·Community based·Vocational·Educational needs·Financial needs·Identify medical interventions necessary·Identify related needs of client& family & caregiver·Identify relevant service providers for client ·State recommended interventions·Identify barriers·Develop contingency plan·Set target dates·Get buy in of pan to client & family ·Bet consent from all concerned(client, caregiver & family)
5.1.1.3. Determine clinical appropriateness and correctness
Undertakings officer
Undertakings officer
Undertakings officer
Undertakings officer
Undertakings officer
Undertakings officer
Undertakings officer
Undertakings officer
Undertakings officer
Undertakings officer
5.1.1.3.2. Apply payment
rule
Is invoice appropriate and
correct? Accept invoice End
5.1.1.3.1. Verify invoice against
pre–authorisation record
Has a pre-authorisation been issued
before?
Reject invoice
Amount reasonable?
No
Yes
Is it a medical invoice?
5.1.1.3.3. Verify clinical
detail
No
Yes
No
Accept invoiceContact service
provider/ claimant to negotiate
Agreement reached?
Adjust invoice / pre-authorisation
Yes
No
Yes End
Accept invoiceYes
No
End
End
Is invoice accepted?
End
No
Yes
Reject invoice
A
A
B
B
5.1.1.3.1. Verify invoice against pre–authorisation record
Undertakings officer
Undertakings officer
Undertakings officer
Undertakings officer
Undertakings officer
Undertakings officer
Undertakings officer
Undertakings officer
Undertakings officer
Undertakings officer
Undertakings officer
Undertakings officer
Undertakings officer
Assess authorisation record in terms of service rendered and authorised
Invoice different from pre-
authorisation record?
Record discrepancyDifference
substantiated?Accept invoice Last invoice? EndYes
No
Yes Yes
No
A
Clinical records substantiate
liability?
Interpret invoice and capture medical
evaluation results
Send medical feedback
Accept invoiceYes
B
A
Negotiate with service provider
Adjust and accept invoice
Reject invoiceAgreement reached?
Medical opinion required?
Distribute invoice to bill reviewer for interpretation
Yes
Record discrepancy
No
YesNo
B
No
Accept invoice
B
Reject invoice
No
BB
B
5.1.1.3.2. Apply payment rule
Undertakings officer
Undertakings officer
Undertakings officer
Undertakings officer
Check if the Fund is liable
Is date of service before undertaking acceptance date?
Duplicate invoice / pre-
authorisation?
Accept invoice
Reject invoice Last invoice? EndYes Yes
No
Yes
No
Last invoice? EndYes
No
No
A
AA
Is the Fund liable?
Yes
Reject offer
No
Last invoice? EndYes
No
A
5.1.1.3.3 Verify clinical detail
Undertakings officer
Undertakings officer
Undertakings senior officer
Undertakings senior officer
Undertakings officer
Undertakings officer
Undertakings officer
Undertakings officer
Undertakings officer
Evaluate diagnosis and treatment
codes
Senior medical opinion
required?
Invoice distributed to Senior bill reviewer for
interpretation
Interpret invoice and capture medical
evaluation results
Send medical feedback
Yes
No
B
A
ALast invoice
item?
Reject invoice
Clinical records substantiate
liability?
Invoice / pre-authorisation
acceptedEnd
Contact service provider/ claimant
to negotiate
Agreement reached?
Adjust invoice / pre-authorisation
Last invoice item?
End
Yes
YesNo
No
Yes
No
Yes
B
C
C
Yes
D
D
D
Update notes on Excel
5.1.1.4. Prepare payment list
Undertakings officer
Undertakings officer
Undertakings officer
Undertakings officer
Undertakings officer
Undertakings officer
Undertakings officer
Generate consolidated list of approved invoices
for payment
Send list to finance for approval and
payment
Finance approves?
Contact undertakings
department to resolve query
Query resolved?
Finance signs, payment is processed
End
Escalate matter and agree on resolution
Finance signs, payment is processed
End
Yes
No
Yes
No
Assistant makes copies of signed
excel and attaches invoices
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