As you are no doubt aware that Discovery has implemented a Day Surgery Network for Coastal, Keycare, Delta and Smart plan Discovery options in 2019. This has resulted in a lot of confusion and uncertainty. After discussions with Discovery the following issues may be relevant:

Discovery has on its website;

  • A list of conditions across all plans that they have deemed to qualify for Daycare procedures.
  • A list of Daycare hospitals (CODE 76/77) and acute hospital facilities (CODE 58) in your area that they have deemed appropriate for the Daycare Surgery Network. An acute hospital facility is a normal hospital that will now cater specifically for daycare work e.g. St Augustine’s and Entabeni.
  • A list of procedures that are absolute scheme exclusions.

PLEASE ACCESS THE DISCOVERY WEBSITE AND FAMILIARISE YOURSELF WITH THIS IMPORTANT INFORMATION.

HOW TO IDENTIFY A PATIENT APPROPRIATE FOR THE DAY SURGERY NETWORK

  • The planned procedure must be on the Daycare surgery list.
  • You need to identify the Discovery plan the patient is on.
  • You need to identify the hospital in your area designated to cater for this plan.
  • You need to identify this as a day surgery procedure when requesting authorization. You must stipulate on your admission form the point of surgery is 24.
  • Perform the surgery.
  • You will be allowed to charge the enhanced remuneration only if the surgery is performed in a designated day hospital (CODE 76/77) or in your rooms.

HOW TO IMPROVE THE LIST OF DAY SURGERY PLANS FOR AN ACUTE HOSPITAL

  • Your manager will need to contact the Discovery team in charge of deciding the plan types appropriate for your hospital.
  • It is likely a motivation be required to support such an application e.g. Number of patients on excluded plan that are managed at the hospital as well as offering a rate that is equivalent to other designated day surgery in that area.

MEDICAL SCHEME LIAISON FOR YOUR HOSPITAL GROUP

Your manager will be familiar with the appropriate liaison to Discovery.

THE SPECIALIST SHOULD NOT CONTACT DISCOVERY IN THIS REGARD. IT MUST BE DONE VIA THE HOSPITAL MANAGER.

KEYCARE ENDOSCOPIES AND COLONOSCOPIES

Despite rigorous and compelling arguments Discovery has not yet agreed to fund Endoscopies and Colonoscopies for patients on Keycare for 2019 except out of specialist benefits (approximately R4500.00 per year) or as a PMB.

These discussions are ongoing and hopefully they will see the ethical merit of allowing these procedures.

REMUNERATION FOR DAY SURGERY

You can only charge the increase in remuneration offered in Day surgery if done at a designated day hospital or in your rooms otherwise the Discovery rate applies. (CODE 76/77)

These discussions are ongoing.

SCHEME EXCLUSIONS

Discovery has also provided a list of scheme exclusions on their website for these plans.

MOTIVATION FOR PATIENTS PROCEDURES OUTSIDE DAYCARE

If the Surgeon decides that one of the listed procedures require more than Day surgery, e.g. Diabetic foot sepsis with cellulitis, a letter of motivation will be required.

Discovery is trying to streamline this and identify these patients and exclude them from the Network pathway and deem them appropriate for in-hospital care.

THESE DISCUSSIONS ARE ONGOING AND IT IS LIKELY THAT THERE WILL BE FURTHER CHANGES WHICH WE HOPE TO UPDATE TIMEOUSLY.

For any queries or comments, please contact our offices via email to info@kznspecialist.co.za.