FAMILY PRACTITIONER NETWORK GUIDE 2019 - Sasolmed FP Network Guide
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FAMILY PRACTITIONER NETWORK GUIDE 2019
INDEX
INTRODUCTION
1 FAMILY PRACTITIONER NETWORK FEES
2 BEING NOMINATED AS AN FP
3 SPECIALIST REFERRAL
4 PHARMACY NETWORKS
5 VALUE-ADD PROGRAMMES/SERVICES
6 TOOLS TO HELP NETWORK FPs
7 HEALTHCARE FORENSICS
8 CONTACT DETAILS
INTRODUCTION
Dear Family Practitioner
Fragmented healthcare has in the past resulted in inefficient, costly
treatment for our beneficiaries. That is why we have introduced the
concept of care co-ordination, as we believe that this not only improves
the quality of healthcare for our beneficiaries, but also lowers overall
health expenditure.
As you are one of our Network FPs, we would like to thank you for the
valuable services that you render to our beneficiaries. We would also like
to make your task as easy as possible, which is why we have put together
this guide. It aims to provide you with all the information you need to treat
Sasolmed beneficiaries effectively, including an overview of Sasolmed’s
value-add programmes and how these can complement your services to
our beneficiaries.
Also note that there will be a 5% increase in the Sasolmed FP tariff rates
with effect from 1 January 2019.
If you have any questions, please call the Healthcare Provider Contact
Centre on 0861 112 666.
We look forward to partnering with you in 2019!
Sasolmed Principal Officer
Shantèl Smit
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1 FAMILY PRACTITIONER
NETWORK FEES
The Sasolmed FP Network reimbursement model for 2019 will continue to include
an enhanced fee, in accordance with the practice’s REPI² category score as indicated
in the table below, and will see a 5% increase in rates from 1 January 2019.
Enhanced Fees
FP Consultation Rates
2019 Automatically added when consult
(0190-0192)
is processed
REPI2 Cat 1 REPI2 Cat 2
Sasolmed Scheme Rate R377.70 R91.40 R63.20
The enhanced fee will automatically be added when the practice is reimbursed for
consultations.
It is important that FPs adhere to their contract requirement to bill the Sasolmed
Scheme Rate, so that members are not faced with unexpected co-payments.
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2
BEING NOMINATED
AS AN FP
At Sasolmed we are so committed to the concept of co-ordinated care, and the key
role of the FP in this regard, that we require our beneficiaries to nominate a specific
Network FP to be the co-ordinator of their care.
If you consult with Sasolmed beneficiaries who ask you to be their nominated FP,
simply ask them to call the Sasolmed Call Centre on 0860 002 134 to arrange for
your nomination on the system.
• Sasolmed pays 100% of the consultation fee for the first two visits to a nominated
in-network FP per beneficiary.
• A 10% co-payment is payable for consultations following the second visit to a
nominated in-network FP.
• A 20% co-payment is payable for consultations to a non-nominated FP who is not
contracted to the Sasolmed FP Network.
• Out-of area visits criteria apply.
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3 SPECIALIST REFERRAL
WHY SASOLMED REQUIRES A SPECIALIST REFERRAL
There is a growing trend of fragmented care, where a number of our beneficiaries
are receiving duplicate treatment from multiple doctors and providers. This leads to
poor patient experience and unsatisfactory outcomes in providing safe, appropriate
Quick reference guide for specialist practice types requiring a specialist referral:
SPECIALIST TYPE
12
SPECIALIST TYPE DESCRIPTION
Dermatologist
and effective care. 16 Gynaecologist
Sasolmed beneficiaries must therefore consult their Network FP BEFORE they 17 Pulmonologist
make an appointment with a specialist, and the FP must then obtain a referral 18 Physician
number for the specialist referral. This will ensure that the patient is referred to
the appropriate specialist. Failing to do so will result in the beneficiary having to pay 19 Gastroenterologist
the specialist claim in full from their own pocket. 20 Neurologist
21/33 Cardiologist and Paediatric Cardiologist
HOW TO OBTAIN A SPECIALIST REFERRAL NUMBER
• Contact the Sasolmed Provider Call Centre on 0861 112 666 and use the 22 Psychiatrist
Interactive Voice Recognition function to obtain a referral number. You will need
24 Neurosurgeon
to have the following information at hand:
28 Orthopaedic Surgeon
–– Your practice number, e.g. 1234567;
–– Your patient’s membership number, e.g. 8810000001; 30 Otorhinolaryngologist (ENT)
–– Your patient’s beneficiary number, e.g. 00; 31 Rheumatologist
–– Your patient’s date of birth in the format DDMMYYYY, e.g. 31121954;
32 Paediatrician
–– The practice type (e.g. 18 for a Physician); and
33 Cardiology Paediatrician
–– The number of months that you want the patient to visit the specialist
(between 1 and 6, e.g. 3). A referral number will automatically be created for 36 Plastic and Reconstructive Surgeon
the beneficiary on the system from the date that you created the referral and 42 Surgeon
adding the number of months you have chosen to create, as well as an end date
for the referral. 44 Cardiothoracic Surgeon
• Specialist Referral can also be done via the web: 46 Urologist
Visit www.medscheme.com > login as a provider > click on Specialist Referral
(and complete all required information).
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4 PHARMACY NETWORKS
Sasolmed has a large pharmacy network that consists of over 1 450 pharmacies,
including Pharmacy Direct, Clicks, Dis-Chem, Medi-Rite, Pick n Pay, Optipharm,
Scriptwise, Netcare and Pharmacross, as well as various independent community
pharmacies. Network pharmacies have agreed to charge contracted dispensing
fees, ensuring that beneficiaries will not be liable for co-payments.
Please find information below regarding designated service providers, preferred
provider networks and co-payments:
CHRONIC MEDICATION BENEFIT RULES
Pharmacy Network Sasolmed has agreements with Clicks, Dis-Chem, Medi-
Rite, Pharmacy Direct, Pick n Pay and various independent
pharmacies. Sasolmed beneficiaries should be reminded to
make use of one of these pharmacies.
How to apply for Please call the Sasolmed Contact Centre on 0861 100 220 or
chronic medicine email sasolmedcmm@medscheme.co.za
You can also log onto www.medscheme.com > login as a
ACUTE MEDICATION BENEFIT RULES
provider > click chronic application > insert membership
number. Pharmacy Network Sasolmed has agreements with Clicks, Dis-Chem, Medi-
Rite, Pharmacy Direct, Pick n Pay and various independent
Changes or updates Changes or updates to chronic medication are done
pharmacies. Sasolmed beneficiaries should be reminded to
telephonically by contacting the Sasolmed Contact Centre on
make use of one of these pharmacies.
0861 100 220.
To find out which pharmacies have agreements with
Chronic formularies Formularies can be viewed at www.medscheme.com > Sasolmed, please call 0860 002 134.
and disease baskets login as provider zx> click on clinical information > medicine
management. Acute formularies Formularies can be viewed at www.medscheme.com >
login as provider > click on clinical information > medicine
Disease baskets can be viewed at www.medscheme.com > log
management.
in as a provider > click lookup tool > disease basket lookup.
Co-payments Co-payments can be avoided by:
Co-payments Co-payments can be avoided by:
Ensuring the patient makes use of the contracted pharmacies;
Ensuring the patient makes use of the contracted pharmacies;
Prescribing in-formulary drugs; and
Prescribing in-formulary drugs; and
Ask the pharmacist to substitute expensive medications with
Ask the pharmacist to substitute expensive medications with
a generic equivalent that will not attract a MPL co-payment.
a generic equivalent that will not attract a MPL co-payment.
Please contact the Sasolmed Contact Centre on 0861 100 220 for any other acute
Please contact the Sasolmed Contact Centre on 0861 100 220 for any other chronic
medication queries.
medication queries.
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5 VALUE-ADD PROGRAMMES/SERVICES
The following programmes/services have been put in place to enhance Sasolmed’s offering to beneficiaries and to ensure quality care at an affordable price. As FP, you can
encourage Sasolmed beneficiaries to make use of these programmes and services, where appropriate.
IMPROVED CLINICAL PATHWAY SERVICES (ICPS),
JOINTCARE AND CARE EXPERT DOCUMENTATION BASED CARE (DBC) PROGRAMME
ICPS, JointCare and Care Expert are service providers for Sasolmed beneficiaries The goal of DBC is to reduce the need for unnecessary surgery caused by chronic
for hip and knee replacements. ICPS, JointCare and Care Expert are groups of back and neck pain and to restore normal function. DBC will, for most patients,
orthopaedic surgeons that specialise in performing hip and knee replacements decrease pain, reduce stiffness and improve mobility.
according to standardised clinical care pathways. These care pathways have been
developed in accordance with evidence-based outcomes to ensure that the quality All qualifying Sasolmed beneficiaries have access to this programme. Beneficiaries
of the hip and/or knee replacement is of the highest standard and to ensure the who are eligible for the programme are proactively identified by the Sasolmed
best health outcomes. beneficiary risk management team. Eligible beneficiaries can also be identified by
their FP, or they can self-refer.
ICPS, JointCare or Care Expert will ensure payment in full for the procedure, which
will include the following: The cost to participate in the DBC programme is covered by The Back and Neck
• All hospital costs; Rehabilitation Benefit. Please note that this excludes the cost of any other
investigations or medication prescribed by a physiotherapist or medical practitioner,
• Surgeons and anaesthetist fees;
in which case acute benefits and Scheme rules will apply. For beneficiaries who elect
• Prosthesis (subject to prosthesis benefit); and not to first use the conservative treatment offered by DBC before back and neck
• Physiotherapist (pre-, intra- and post-operative). surgery is performed, back and neck surgery will not be covered, except in the case
of an emergency.
If you have a patient who requires a hip and knee replacement, please call the
Sasolmed Provider Contact Centre on 0861 112 666 for details of ICPS, JointCare Should you wish to enrol your patient in the DBC Programme, please call the
or Care Expert orthopaedic surgeons close to the beneficiary, and for a specialist Sasolmed Call Centre on 0860 002 134 to determine whether your patient
referral number. qualifies to be enrolled on this programme.
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MENTAL HEALTH PROGRAMME
Patient activation and empowerment is becoming an important focus area
in the management of chronic diseases. However, this may be a particularly
difficult achievement in the patient with a mental disorder. In recognition of this, WEIGHT MANAGEMENT PROGRAMME
Sasolmed offers a Mental Health Programme that employs innovative solutions for
empowerment, and leverages off social, family and workplace support.
Sasolmed’s Weight Management Programme has been expertly designed for
qualifying Sasolmed beneficiaries (those with a high BMI and waist circumference).
Benefits of the programme, compared to usual care, are as follows:
• Greater reduction in mental health symptoms; Under the Weight Management Programme, beneficiaries will participate in a 12-
• Greater rates of care for mental health; week, biokineticist-led intervention plan that will give them access to a dietician and
• Improvement in quality of life; a psychologist, with the goal of losing excess weight and leading healthier, more
rewarding lives. Once the programme is completed, ongoing advice and monitoring
• Less functional impairment;
will also be made available to participating beneficiaries.
• Better patient satisfaction;
• Better provider satisfactio; and Sasolmed beneficiaries with the following parameters will be eligible for
• Significant benefits in terms of absenteeism reduction . the programme:
• BMI ≥ 30 kg/m², or
The Mental Health Programme follows an internationally successful model of • Men with a waist circumference ≥ 102 cm, or
integrating mental healthcare into the primary care setting, through effective
• Women with a waist circumference ≥ 88 cm, or
collaboration between family practitioners, specialists and auxiliary caregivers, and
the introduction of a Care Manager to help co-ordinate the process. • Other cases identified by a Family Practitioner or BASA biokineticist supported by
a motivation e.g. beneficiary with a BMI between 25.0 kg/m² and 29.9 kg/m² with
Should you require more information about the Mental Health Programme, diabetes and comorbidities.
or wish to confirm whether your patient meets the criteria of the Sasolmed
Mental Health Programme, please call 0860 106 155 and follow the prompts to To find out more about the Weight Management Programme, or to enrol your
select the Mental Health Programme, or email mentalhealth@sasolmed.co.za. patient, please call 0860 106 155.
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PAED-IQ BABYLINE
BabyLine is part of PAED-IQ (Pty) Ltd, which has been in existence for 5 years and is a
SASOLMED SMOKING CESSATION PROGRAMME South African-based medical information company, seeking to provide information
and services to parents and caregivers, that will enhance the level of care they are
Sasolmed offers all beneficiaries the opportunity and support to stop smoking. This able to provide to their children.
is done via the Allen Carr Easyway to Stop Smoking Programme.
PAED-IQ partnered with the Paediatric Management Group of South Africa, a body
Features of the programme include: that represents the majority of Paediatric Specialists in private practice in South
Africa. Through this collaboration, a database of information on common health
• Internationally renowned programme;
conditions in children was developed. This information is tailored to the needs of
• Endorsed by the Cancer Association of South Africa (CANSA);
South African children and is endorsed by the Paediatric Management Group of
• One of the world’s most successful smoking cessation programmes; South Africa.
• Examines and addresses the reasons why people smoke ;
Sasolmed has partnered with PAED-IQ to educate Sasolmed parents and ensure
• Drug free programme;
their benefits last longer. BabyLine offers a paediatric telephone triage service,
• One interactive group session of approximately 5 hours;
which is available 24/7, 365 days a year. The service offers healthcare advice to
• Two back up sessions if required; and parents with children under 3 years of age and is delivered by skilled personnel
• Clinics available across South Africa (Johannesburg, Cape Town, Port Elizabeth, (registered nurses).
Durban, East London).
Sasolmed members will have access to this helpline, free of charge and can dial
Please assist Sasolmed beneficiaries who want to participate in this programme 0860 999 121 to make use of the service.
totally free of charge by calling 0861 100 200 or visit www.allencarr.co.za For more information on PAED-IQ, please visit paediq.com.
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ELECTRONIC MEDICAL RECORD
The Electronic Medical Record (EMR) is a digital version of a patient’s paper-based
chart and aims to make it easier to share Sasolmed beneficiaries’ clinical and
demographic information with FPs who are on the Sasolmed FP Network.
care pathways that take into account clinical and financial implications, while at the
same time being aligned to beneficiary benefits and a primary healthcare approach.
Going forward, care pathways will be shared with healthcare professionals and will
also be incorporated into the EMR.
The Independent Practice Association (IPA) Forum and Sasolmed Clinical Coordina-
tion Committee (SCCC) have provided their input with regard to the EMR. To date, a hypertension care pathway and a diabetes mellitus care pathway
have been developed and can be accessed by visiting the Medscheme website
The EMR provides FPs with the following administrative and clinical benefits: at www.medscheme.com > Communication library > Communication > General
Communication. Below is an extract of the hypertension care pathway that has
been developed.
ADMINISTRATIVE BENEFITS CLINICAL BENEFITS
• Decreased paperwork • Access to up-to-date patient
BP 140-159 / 90-99 BP 140-159 / 90-99
• Decreased storage cost information, including clinical notes mmHg with7 HEALTHCARE FORENSICS
Sasolmed uses world-class analytical software, Insurance Fraud Manager (IFM)
developed by FICO, which employs advanced mathematical techniques to detect
suspicious and abnormal claiming patterns. This ensures that our beneficiaries
receive the best and appropriate patient care at all times, whilst minimising the
financial impact of fraud, waste and abuse.
The claiming process for all healthcare professionals remains as is. Please continue
to submit all claims as per the existing process. Valid claims will be assessed and
paid. The claims data will then be reviewed to identify abnormal claiming patterns.
If claims are found to be inappropriate, the relevant healthcare professional will be
consulted to address the findings. Corrective measures will then be discussed and
agreed upon to address the irregular claiming behaviour.
Fraud, waste and abuse will continue to be addressed in a fair and transparent
manner, which includes taking into account best practice and clinical necessity,
where relevant.
A healthy claims audit and forensic capability enables Sasolmed to strengthen
our ties with all healthcare professional bodies and ensures that we continue to
work towards achieving our goal for holistic patient-centric and affordable care at
all times.
For any fraud-related queries, please contact the fraud hotline on 0800 112 811 or
email fraud@medscheme.co.za.
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SERVICE
Healthcare Professional
Contact Centre (IVR)
PURPOSE
General queries related to
TELEPHONE EMAIL ADDRESS FOR QUERIES
including Website Assistance 0861 112 666 sasolmed@medscheme.co.za
Sasolmed
/ Sasolmed Provider Contact
Centre
Chronic Medicine Chronic submissions and
0861 100 220 sasolmedcmm@medscheme.co.za
Management queries
Disease Management Disease management updates 0860 106 155 diseasemanagement@medscheme.co.za
Fraud Hotline Fraud-related matters 0800 112 811 fraud@medscheme.co.za
All hospital pre-authorisations
Hospital Pre-Authorisation 0861 100 220 sasolmed.authorisations@medscheme.co.za
for non-emergency events
Submissions of claims for
Submission of claims 0861 112 666 claimsmanagement@medscheme.co.za
Sasolmed beneficiaries
Queries relating to a claim for a
Queries of claims 0861 112 666 queries@sasolmed.co.za
Sasolmed beneficiary
Oncology Services Oncology-related queries 0861 100 220 cancerinfo@medscheme.co.za
Ambulatory PMB Ambulatory PMB queries 0861 100 220 sasolmedapmb@medscheme.co.za
Aid for Aids Aid for Aids Management 0800 227 700 afa@afadm.co.za
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