JURÍDICO PRESUPUESTARIO
B).- Estructura y contenido
III.- LA REFORMA DEL MARCO JURÍDICO DE ESTABILIDAD PRESUPUESTARIA. PRESUPUESTARIA
General
ISH_CV_FR: Interim Billing for Rehabilitation Cases (SSR) (Changed)
As of SAP enhancement package 7 for SAP ERP 6.0, Industry Extension Healthcare (IS-H 617), business function SAP Patient Management: Country Version France (ISH_CV_FR), as well as in the Support Packages listed below, you can now perform interim billing for rehabilitation cases.
If you have assigned a contract scheme that allows interim billing to an inpatient rehabilitation case, you can also perform live billing for this case on a specified date, even if the case has not yet been discharged.
Contract schemes with interim billing must meet with certain criteria if billing is to take place correctly. For example, there should be no maximum amounts or portions < 100% defined for contract schemes with interim billing. The system does not check whether the contract scheme you create can obtain correct results in interim billing. There is also no check to determine whether subsequent changes to patient, case, or movement data have invalidated existing interim billing runs.
This change is available with the following Support Packages:
SAP ERP 6.0, Industry Extension Healthcare, SAP enhancement package 5 (IS-H 605), Support Package 12, business function SAP Patient Management Country Version France (ISH_CV_FR) SAP ERP 6.0, Industry Extension Healthcare, SAP enhancement package 6 (IS-H 606), Support Package 04, business function SAP Patient Management Country Version France (ISH_CV_FR)
ISH_CV_FR: FIDES – Dir. Billing with Soc. Ins. for Outp. Cases (Enhanced)
The following enhancement isavailable as of SAP enhancement package 7 for SAP ERP 6.0, Industry Extension Healthcare (IS-H 617), business function SAP Patient Management: Country Version France (ISH_CV_FR), as well as with the Support Packages listed below:
The French Ministry of Health is switching from billing outpatient services for state hospitals from a global budget to direct individual billing to the social insurance fund. This billing reform is known in France by the abbreviation FIDES-ACE (Facturation Individuelle Directe des Etablissements de Santé des Actes et Consultations Externes). It applies exclusively to outpatient cases in acute care (MCO) and to sales of drugs from the hospital pharmacy. This means it does not apply to inpatient and day patient cases in acute care or to cases in rehabilitation (SSR), psychiatry, home care (HAD), and nursing homes (EHPAD).
The FIDES-ACE reform is currently being piloted and will be rolled out from January 2013.
FIDES-ACE billing is referred to below as "direct billing".
Direct billing is based on a legally defined basic service price, which is multiplied by one or both of the following coefficients depending on the type of service to determine the price for which the social insurance fund is to be billed:
Transition coefficient ("coefficient transitoire") Geographical coefficient ("coefficient géographique")
According to legal regulations, the transition coefficient has been set to 1 for all hospitals in France.
These coefficients can only be taken into account when calculating the price of the portion of a service for which the state health insurance fund is to be billed. The patient contribution towards the service must not be affected by these coefficients.
The coefficients are not taken into account in billing cases outside the area of T2A (areas M, C, O, and N), for example SSR or PSY cases.
To be more precise, the transition coefficient must be used for the following services:
CCAM services NGAP services
NABM services (lab services)
Radiology flat rates (FTG, FTN, FTR) Outpatient flat rates (ATU, FFM, SE)
In addition, the geographical coefficient must be used to calculate the reimbursement basis for state health insurance funds for the following services:
Outpatient flat rates (ATU, FFM, SE) Example:
See B2 documentation, appendix 27, case 1
Billing of consultation service CS with a basic price of EUR 23.
The transition coefficient is 1.1. The state health insurance fund covers 70% of the service.
The state health insurance fund reimburses (EUR 23 * 1.1) * 0.7 = EUR 17.71
The amount for the patient or for the complementary insurance fund is: EUR 23 * 0.3 = EUR 6.90 Activating FIDES Billing
If your hospital wants to switch to direct billing from a key date, you must activate these new billing rules and also make additions to the pricing procedure.
The following new Customizing activity is available for activating FIDES billing: SAP Healthcare – Industry-Specific Components for Hospitals Patient Accounting Billing Configure Special Forms of Billing Control Billing Modes.
You can enter the key date from which direct billing is to be active in this activity. As of this date, the system uses the rules for direct billing, and automatically uses the B2 version June 2005 Addendum D for the EDI procedure FRB2.
Configuring the Coefficients in the Pricing Procedure
To have the system process the transition coefficient and the geographical coefficient in pricing, you must define the values of the coefficients in Customizing, as well as define corresponding condition types and add them to the pricing procedure.
You maintain the values for the transition and geographical coefficient in Customizing under SAP Healthcare – Industry-Specific Components for Hospitals Patient Accounting Billing Configure Special Forms of Billing Billing Parameters (Institution- and Time-Dependent).
Then create the following condition types in Customizing under SAP Healthcare – Industry-Specific Components for Hospitals Patient Accounting Billing Pricing (Using Conditions) Conditions
Define Condition Types:
Transition Coefficient
Define a condition type with the following data:
Condition class A (surcharges or discounts) Calculation rule G (formula)
Item condition X
Then specify this condition type in your pricing procedure with requirement 120 and calculation formula 72.
Geographical Coefficient
Define a condition type with the following data:
Condition class A (surcharges or discounts) Calculation rule G (formula)
Item condition X
Then specify this condition type in your pricing procedure with requirement 121 and calculation formula 73.
To correct the surcharges correctly, the entries of the conditions for the coefficients must build on each other; in other words, a subsequent condition (such as the geographical coefficient) must include the previous surcharge coefficient in its calculations.
In addition, the condition for the deduction of the fixed patient contribution portion of € 18 (formula 139) must follow on from the entries for the two coefficients.
The rounding condition (formula 138) can be positioned before the coefficient surcharges, since the rounding condition cannot process these surcharges for technical reasons.
Rounding differences resulting from the coefficients are taken into account and cleared when calculating the surcharges.
Service Entry
In case-related service entry, you can now enter a tooth number for dental services. The tooth number is displayed in the B2 message in direct billing (June 2005D version).
You enter the number of a tooth in the "Tooth Number" field in case-related service entry.
The BAPIs for entering service data have also been enhanced accordingly.
Addition of Specialties
FIDES direct billing applies to acute care
Until now, acute care was identified by the areas M/C/O (Médecine, Chirurgie, Obstétrique = internal medicine, surgery, obstetrics), with obstetrics and dentistry grouped under "O". With the introduction of direct billing, dentistry has been separated from obstetrics and included as a separate area, "N".
To perform billing correctly, you must define a new specialty key for dentistry. To do this, choose SAP Healthcare – Industry-Specific Components for Hospitals Hospital Basic Data Hospital Structure Organizational Structure Code Specialties in Customizing and define a new "Dentistry" entry for specialty category 7. Assign this new entry the unique key N (in field UNQCD).
Then assign the organizational units for dentry in your organizational structure to this specialty key.
You must enter a unique key (if appropriate) for all existing entries for specialty category 7, regardless of whether or not you have activated FIDES billing.
The following keys are available:
C Surgery HAD Home care M Internal medicine
N Dentistry O Obstetrics P Nursing home SSR (new)
FIDES-ACE: Uniform Coverage Rate for Medical Services and Hospital Flat Rates
If medical services such as CCAM, NGAP, or NABM services are billed together with one of the flat rates ATU (emergency), FFM (material), or SE (outpatient intervention), the state health insurance fund covers the same percentage of the CCAM, NGAP, or NBAM services as the flat rates. This means the system must use the state HI coverage rate that applies to the flat rates for the CCAM, NGAP, or NABM services during billing.
The state health insurance fund usually covers 70% of CCAM and NGAP services and 60% of NABM services (lab services). The coverage rate for ATU, FFM, and SE flat rates is 80%. If a CCAM, NGAP, or NABM service is included in the same invoice as one of the flat rates, the coverage rate for the state health insurance fund for CCAM, NGAP, and NABM services must also be 80%.
You define coverage rates for services in contract schemes in the system.
To meet these requirements, you must define a separate contract scheme in the system, where the coverage rates are the same for the flat rates and for CCAM, NGAP, and NABM services.
You can create contract schemes in Customizing under SAP Healthcare – Industry-Specific Components for Hospitals Patient Accounting Business Partners / Insurance Relationships SG,CA,CH,FR,IT: Maintain Contract Schemes.
You should also note that you may also need to configure the function for determining the billing type for new contract schemes.
For more information about determining the billing type, see SAP Healthcare – Industry-Specific Components for Hospitals Patient Accounting Billing Determine Billing Types in Customizing.
You must assign this contract scheme to the insurance relationship with the state health insurance fund if you bill flat rates (ATU, SE, or FFM) together with CCAM, NGAP, or NABM services.
You can activate a check in the system that supports you in identifying the above situation and issues a warning or error message if the contract scheme for the state health insurance fund does not match the value you specified.
To activate this check, activate the BAdI ISH_INVOICE_CHECK (method INVOICE_CHECK) and adjust the sample coding to include your contract scheme. When doing this, you can also decide whether the system is to issue a warning or an error message if the contract scheme is different. If you choose to display a warning, you can execute test billing but live billing is not possible.
For more information about the standdard check, see the BAdI documentation:
SAP Healthcare – Industry-Specific Components for Hospitals Patient Accounting Billing Business Add-Ins for Billing BAdI: Check Invoice Creation.
Generating Dermatology Flat Rates (FSD), Video Capsule Flat Rates (VDE), and SE Flat Rates (SE)
Billing of dermatology (FSD), video capsule (VDE), and outpatient intervention (SE) flat rates is only allowed by law if billing certain CCAM services.
The list of CCAM services that allow billing for these flat rates is described on page 14 of the document "FIDES Cahier des charges"
(http://www.sante.gouv.fr/IMG/pdf/FIDES-Cahier_des_charges_ACE_V0_3.pdf).
The system can support you by generating the FSD flat rate automatically as soon as a corresponding CCAM has been created.
To use the function for automatic generation of the FSD flat rate, you must activate service rule F16 and maintain the related Customizing tables.
Please note that you must create the FSD flat rate in the service master with the new charge type "FS" and the VDE flat rate with the new charge type "FV".
For more information about service rule F16, see the following Customizing documentation:
SAP Healthcare – Industry-Specific Components for Hospitals Patient Accounting Service Rules Country-Specific Service Rules Inclusion for Service Pair CCAM (F16).
Billing Fixed Patient Contribution (€ 18) and Flat Rates
When billing the fixed patient contribution of € 18 for an outpatient visit, the exemption also applies to the flat rate that is billed in addition to the CCAM services. The system supports you by copying the exemption for the CCAM service automatically to the assigned flat rate service.
The system deducts the patient contribution (currently EUR 18) automatically from the most expensive CCAM service.
Flat rates are only covered by state health insurance funds if the assigned CCAM service has insurance verification. If the CCAM service is only refunded under certain conditions according to the master data, the system only assigns the service to the insurance fund if it has insurance verification.
Coordinated Care Path (PSC)
The patient contribution for a service increases if the coordinated care path is not adhered to. This rule also applies to FSD and VDE flat rates but not to the following: FTN, FTR, FTG, ATU, SE, and FFM.
You do not need to make any specific settings for service rule F20; it takes account of the above rule and does n ot generate a PSC patient contribution service for services belonging to charge type FC (technical flat rates FTN and so on), FB (ATU), FE (SE services), and FF (FFM) if the outpatient visit takes place outside of the coordinated care path.
For more information about service rule F20, see the following Customizing documentation:
SAP Healthcare – Industry-Specific Components for Hospitals Patient Accounting Service Rules Country-Specific Service Rules Generate PSC Patient Contribution for Care Path (F20).
CMUC and AMEC complementary insurance covers the increased patient contribution if the
coordinated care path is not adhered to. This means you must define the contract schemes for CMUC and AMEC insurance in such a way that the PSC patient contribution service is covered.
FIDES: EDI Data Exchange
Data exchange with social insurance funds currently takes place using the EDI procedure FRB2. The procedure complies with the rules for communication procedure B2, norm CP, version June 2005, addendum B.
Direct FIDES-ACE billing uses the communication procedure B2, norm CP, version June 2005, addendum D. With the switch to direct billing for outpatient visits, the system creates B2 messages according to the rules and message format for communication procedure B2, version 2005, appendix D.
Outpatient cases: The system now checks which message format is to be used, according to the visit date and invoice recipient. If FIDES billing is active, the system creates messages for the EDI
procedure FRB2 according to B2 format 2005, addendum D. The system still creates B2 messages for outpatient visits made before FIDES billing was activated according to B2 format 2005, addendum B.
Inpatient cases: FIDES billing for inpatient cases is not yet supported.
The switch is made automatically when you activate the billing mode "FIDES". Once you have
activated it, the system creates messages for the B2 procedure with the appropriate message formats.
During file creation (report RNC30101), the system creates separate files for the different message formats. Messages belonging to the "old" B2 procedure (formatted according to B2, version 2005, appendix B) are not stored in the same file as the new FIDES messages (B2, version 2005, appendix D).
Due to the introduction of direct billing, you will need to adjust your settings in the
Customizing table of control settings for B2 dispatch, in particular the setting relating to data transfer to FI (SAP Healthcare – Industry-Specific Components for Hospitals
Communication Electronic Data Interchange Country Specifics Country Specifics for France Control Settings for B2 Dispatch).
Number Ranges
As before, specific number ranges are used for the B2 procedure (ZB2_xxxxx).
Radiology flat rates are billed to account for the use of the equipment. These flat rates (FTN, FTR, and FTG) must be reported in the B2 message in type 3 with the following values for the service
department (type 3, items 41-43) and treatment mode (type 3, items 39-40):
MRI: DMT 753 / MT 19 SCAN: DMT 035 / MT 19 Tomography: DMT 750 / MT 19
The sample implementation of BAdI /ISHFR/ISH_FR_B2 (method
/ISHFR/IF_EX_ISH_FR_B2~CHANGE_B2_DATA) to fill the above fields has been adjusted to accommodate these additional rules.
This enhancement is available with the following Support Packages:
SAP ERP 6.0, Industry Extension Healthcare, SAP enhancement package 5 (IS-H 605), Support Package 13, business function SAP Patient Management Country Version France (ISH_CV_FR) SAP ERP 6.0, Industry Extension Healthcare, SAP enhancement package 6 (IS-H 606), Support Package 04, business function SAP Patient Management Country Version France (ISH_CV_FR)
ISH_CV_FR: AME Billing Reform (New)
As of SAP enhancement package 7 for SAP ERP 6.0, Industry Extension Healthcare (IS-H 617), business function SAP Patient Management: Country Version France (ISH_CV_FR), as well as in the Support Packages listed below, you can use a new form of billing.
With the AME billing reform, new billing rules have been introduced for patients who are insured with the state health insurance fund (AME).
The reform applies to patients who also meet the following criteria:
Inpatient stay in acute care (MCO) or home care (HAD)
The insurance provider is marked as the state health insurance fund.
The patient is not an alien.
The discharge took place after December 31st, 2011.
Two new coefficients are used in billing for these cases:
The permanent AME billing coefficient (corresponds to a surcharge of 30%) is used for all GHS and GHT services.
The AME transition coefficient increases the AME billing coefficient by 2% up to December 2013.
This means state hospitals bill as follows:
20% of the per diem fee (PJ) * length of stay * (permanent AME billing coefficient + AME transition coefficient) + daily hospital rate (FJ) for discharge day
Private hospitals now bill GHS services as follows:
100% GHS * MCO coefficient * permanent AME billing coefficient + daily hospital rate (FJ) for discharge day
New Per Diem Fee Service (Grouping Code PJC)
Create a new service (similar to the per diem fee PJ) with the grouping code PJC in the service master data. Its price is 20% of the daily hospital rate.
Change to Service Rule F10
A new Special Coverage column is available in the Customizing table for the service rule Generate Per Diem Fee (/ISHFR/TNWFR_F10). You can use this column to have the system generate the new per diem fee (PJC) for AME cases.
For more information, see the Healthcare Implementation Guide under SAP Healthcare – Industry-Specific Components for Hospitals Patient Accounting Service Rules Country-Specific Service Rules Generate Per Diem Fee (F10).
AME Billing Coefficient
The billing coefficient for state health insurance (AME coefficient) comprises a permanent billing coefficient and an AME transition coefficient.
You specify the total of the two coefficients in the AME Coefficient parameter (AME_FACT) in the institution-related, country-specific control table (/ISHFR/PARAM).
If the hospital does not bill by per diem fees but instead performs GHS billing, there is no transition coefficient. In this case, you only specify the permanent AME billing coefficient.
Condition for AME Billing
The AME coefficient is used when the following conditions apply:
The case in question is in inpatient acute treatment (MCO) or home care (HAD).
The insurance relationship for the social insurance fund is marked as "state health insurance"
(NCIR-/ISHFR/IPCAT = AME).
The patient is not an alien.
The discharge took place after December 31st, 2011.
The service has charge type FA (per diem fee), F5 (GHS), or F7 (GHT).
The price of the service has not been changed manually.
To include the new AME billing coefficient in billing, you must define your own condition for it and add this to the pricing procedure. To do this, proceed as described below.
Define Condition Type
Define a customer-specific condition type with the following data:
Condition class A (surcharges or discounts) Calculation rule G (formula)
Item condition X
To do this, choose SAP Healthcare – Industry-Specific Components for Hospitals Patient Accounting Billing Pricing (Using Conditions) Conditions Define Condition Types in
Customizing.
You must also define a customer-specific requirement and calculation formula.
For more information about creating the requirement and the calculation formula, see SAP Healthcare – Industry-Specific Components for Hospitals Patient Accounting Billing Configure Special Forms of Billing Notes on Configuring Special Forms of Billing Example 17 in Customizing.
Maintain Pricing Procedure
Then specify this condition type in your pricing procedure with requirement xxx and calculation formula xxx. ("xxx" stands for the requirement and calculation formula you created.)
This condition must be processed in the pricing procedure after the condition for the GHS reduction (condition with calculation formula 131 for the discount for stays < low trim point and readmissions), and that the levels (reference levels from and to) of the condition must be the same as those of the condition for the GHS reduction.
This condition must be processed in the pricing procedure after the condition for the GHS reduction (condition with calculation formula 131 for the discount for stays < low trim point and readmissions), and that the levels (reference levels from and to) of the condition must be the same as those of the condition for the GHS reduction.