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The complexity of medical tariff codes in South Africa


Medical aid tariff codes are used by all medical aid schemes to indicate the type of treatment or service provided by a healthcare provider and the associated cost. It is essential to bill according to the contract laid out between the provider and the medical scheme or payments will be delayed.

Why do we need medical tariff codes

Medical aid tariff codes are used by all medical aid schemes to indicate the type of treatment or service provided by a healthcare provider and the associated cost. Each of these codes have an amount attached to it which determines the rate at which any medical service provider will be paid.

Prior to the medical tariff code list being established, practitioners, professional bodies, funders and stakeholders used to operate in an unclear environment on what fees to charge for services rendered. Tariff codes provide clarity, guidelines, and criteria within a contested environment.

National Health Reference Price List (NHRPL)

In 2006 the National Health Reference Price List (NHRPL) was established by the Council for Medical Schemes in conjunction with the Department of Health. It was published by the South African Medical Association (SAMA) in the doctors billing manual alongside the HPSCA and compensation fund tariff. In 2006 NHRPL was adopted by the HPCSA as the ethical tariff.

In 2007 the National Department of Health subsequently published “regulations relating to the obtainment of information and the process of determination and publication of reference price list.” In 2008 the council decided to scrap the ethical tariff from the HPCSA with the effect from the date of publication of the Reference Price List by the Department of Health.

In 2010 the Department of Health’s reference price list was reviewed and declared invalid. The need for the development of the Guideline Tariffs by the medical professions board was based on complaints received from the public on the overcharging by practitioners in the absence of a recent tariff guideline. The ultimate purpose of the development of the Guideline Tariffs is to ensure an accessible, affordable and sustainable health care system in terms of the constitution.

What has replaced the NHRPL?

Since July 2010 with the demise of the National Health Reference Price List (NHRPL), there has been no uniform standard for medical aid tariffs. The healthcare industry in South Africa, as well as the general public, also refers to medical aid tariffs as “medical aid rates”. As from the 2011 benefit year, medical schemes have been left to devise their own medical tariff and rates structures.

Billing according to the practitioner’s medical aid agreement

The medical service provider is responsible for billing according to the contract laid out between either the patient and the provider or the medical scheme and the provider. Should the service provider not bill according to the agreement it can delay payment or result in non-payment or short-payments.

Medical schemes have the right to hold all payments for future patients and reverse old patients, while auditing a practice to ensure that the correct rate was paid. Should the medical scheme decide to audit a practice the Provider will not have any income from the specific scheme for months.

Complexity of medical tariffs

On top of understanding the tariffs specific to each medical scheme, the practitioner needs to apply the correct modifier codes to these tariffs. A modifier is a code that is attached to the tariff code and enables the practitioner to indicate that a service or a procedure that has been performed has been altered by some specific circumstance. By using modifiers correctly, the claim is quickly processed by the medial aid and paid without delay. Neglecting to use a modifier can result in slower payment. Using the modifier incorrectly can result in payment when payment was not due.

Even if the modifier doesn’t change the payment it is essential that they are used correctly for compliance and revenue reporting. Appending modifiers often falls to coders, who need to know the rules and are able to make the assessment.

SAMA medical coding updates

The Medical Doctor’s coding manual is updated annually. Medical Schemes do not always accept the changes in good time and members can be held liable for shortfalls from the scheme.

There were significant changes in 2021 that had a big impact on some providers. For example, code 0019 (a modifier coded should a baby weigh less than 2500) has been discontinued for neonatologist and paediatricians. Another examples is the Psychotherapy items were discontinued in attempt to help Psychiatrist to earn more for what is usually done in the background without the patient being present. The units for the codes did not calculate in a way that was wished for and effected the Psychiatrists negatively.

Work with medical billing experts

It is very important for medical practitioners to work with people who understand the complex world of medical aid tariffs. Synchramed are experts in the area of medical billing - it is our job to understand medical aid tariffs and modifiers; to quickly interpret and action medical aid rejections and queries. Partnering with Synchramed will give the practitioner more free time and less hassle, improve cash flow and reduce bad debt. Stop being weighed down by administrative issues and contact Synchramed today!

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