Compensation for Occupational Injuries and Diseases Act, 1993 (Act No. 130 of 1993)Scale of FeesAnnual Increase in Medical Tariffs for Medical Service Providers, Pharmacies and Hospital Groups - 2012General Information |
The Employee and the Medical Service Provider
The employee is permitted to freely choose his own service provider e.g. doctor, pharmacy, physiotherapist, hospital, etc. and no interference with this privilege is permitted, as long as it is exercised reasonably and without prejudice to the employee or to the Compensation Fund. The only exception to this rule is in case where an employer, with the approval of the Compensation Fund, provides comprehensive medical aid facilities to his employees, i.e. including hospital, nursing and other services - section 78 of the Compensation for Occupational Injuries and Diseases Act refers.
In terms of section 42 of the Compensation for Occupational Injuries and Diseases Act the Compensation Fund may refer an injured employee to a specialist medical practitioner of his choice for a medical examination and report. Special fees are payable when this service is requested.
In the event of a change of medical practitioner attending to a case, the first doctor in attendance will, except where the case is transferred to a specialist, be regarded as the principal. To avoid disputes regarding the payment for services rendered, medical practitioners should refrain from treating an employee already under treatment by another doctor without consulting / informing the first doctor. As a general rule, changes of doctor are not favoured by the Compensation Fund, unless sufficient reasons exist.
According to the National Health Act no 61 of 2003, Section 5, a health care provider may not refuse a person emergency medical treatment. Such a medical service provider should not request the Compensation Fund to authorise such treatment before the claim has been submitted to and accepted by the Compensation Fund. Pre-authorisation of treatment is not possible and no medical expense will be approved if liability for the claim has not been accepted by the Compensation Fund.
An employee seeks medical advice at his own risk. If an employee represented to a medical service provider that he is entitled to treatment in terms of the Compensation for Occupational Injuries and Diseases Act and yet failed to inform the Compensation Commissioner or his employer of any possible grounds for a claim, the Compensation Fund cannot accept responsibility for medical expenses incurred. The Compensation Commissioner could also have reasons not to accept a claim lodged against the Compensation Fund. In such circumstances the employee would be in the same position as any other member of the public regarding payment of his medical expenses.
Please note that from 1 January 2004 a certified copy of an employee's identity document will be required in order for a claim to be registered with the Compensation Fund. If a copy of the identity document is not submitted the claim will not be registered but will be returned to the employer for attachment of a certified copy of the employee's identity document. Furthermore, all supporting documentation submitted to the Compensation Fund must reflect the identity number of the employee. If the identity number is not included such documents cannot be processed but will be returned to the sender to add the ID number.
The tariff amounts published in the tariff guides to medical services rendered in terms of the Compensation for Occupational Injuries and Diseases Act do not include VAT. All accounts for services rendered will be assessed without VAT. Only if it is indicated that the service provider is registered as a VAT vendor and a VAT registration number is provided, will VAT be calculated and added to the payment, without being rounded off.
The only exception is the "per diem"' tariffs for Private Hospitals that already include VAT.
Please note that there are VAT exempted codes in the private ambulance tariff structure.
Claims with the Compensation Fund are processed as follows:
| 1) | New claims are registered by the Compensation Fund and the employer is notified of the claim number allocated to the claim. The allocation of a claim number by the Compensation Fund, does not constitute acceptance of liability for a claim, but means that the injury on duty has been reported to and registered by the Compensation Commissioner. Enquiries regarding claim numbers should be directed to the employer and not to the Compensation Fund. The employer will be in the position to provide the claim number for the employee as well as indicate whether the claim has been accepted by the Compensation Fund |
| 2) | If a claim is accepted as a COIDA claim, reasonable medical expenses will be paid by the Compensation Commissioner. |
| 3) | If a claim is rejected (repudiated), accounts for services rendered will not be paid by the Compensation Commissioner. The employer and the employee will be informed of this decision and the injured employee will be liable for payment. |
| 4) | If no decision can be made regarding acceptance of a claim due to inadequate information, the outstanding information will be requested and upon receipt, the claim will again be adjudicated on. Depending on the outcome, the accounts from the service provider will be dealt with as set out in 2 and 3. Please note that there are claims on which a decision might never be taken due to lack of forthcoming information. |
Billing Procedure
| 1) | The first account for services rendered for an injured employee (INCLUDING the First Medical Report) must be submitted to the employer who will collate all the necessary documents and submit them to the Compensation Commissioner. |
| 2) | Subsequent accounts must be submitted or posted to the closest Labour Centre. It is important that all requirements for the submission of accounts, including supporting information, are met. |
| 3) | If accounts are still outstanding after 60 days following submission, the service provider should complete an enquiry form, W.CI 20, and submit it ONCE to the Labour Centre. All relevant details regarding Labour Centres are available on the website www.labour.gov.za. |
| 4) | If an account has been partially paid with no reason indicated on the remittance advice, a duplicate account with the unpaid services clearly marked can be submitted to the Labour Centre, accompanied by a WCI 20 form. (*see website for example of the form). |
| 5) | Information NOT to be reflected on the account: Details of the employee's medical aid and the practice number of the referring practitioner. |
| 6) | Service providers should not generate: |
| a) | Multiple accounts for services rendered on the same date i.e. one account for medication and a second account for other services. |
| b) | Accumulative accounts - submit a separate account for every month. |
| c) | Accounts on the old documents (W.Cl 4/ W.Cl 5/ W.CI 5F) New *First Medical Report (W.CI 4) and Progress / Final Medical Report (W.CI 5 / W.CI 5F) forms are available. The use of the old reporting forms combined with an account (W.CL 11) has been discontinued. Accounts on the old medical reports will not be processed. |
* Examples of the new forms (W.CI 4 / W.CI 5 / W.CI 5F) are available on the website www.labour.gov.za.
Minimum Requirements for Accounts Rendered
Minimum information to be indicated on accounts submitted to the Compensation Fund:
| ➢ | Name of employee and ID number |
| ➢ | Name of employer and registration number if available |
| ➢ | Compensation Fund claim number |
| ➢ | DATE OF ACCIDENT (not only the service date) |
| ➢ | Service provider's reference and invoice number |
| ➢ | The practice number (changes of address should be reported to BHF) |
| ➢ | VAT registration number (VAT will not be paid if a VAT registration number is not supplied on the account) |
| ➢ | Date of service (the actual service date must be indicated: the invoice date is not acceptable) |
| ➢ | Item codes according to the officially published tariff guides |
| ➢ | Amount claimed per item code and total of account |
| ➢ | It is important that all requirements for the submission of accounts are met, including supporting information, e.g: |
| • | All pharmacy or medication accounts must be accompanied by the original scripts |
| • | The referral notes from the treating practitioner must accompany all other medical service providers' accounts. |