Guidelines to Providers of COVID-19 Admissions

Dear Heritage Health Healthcare Service Provider,

RE: Funding for the right patient, in the right facility, at the right time - Guidelines of the diagnosis and management of Covid-19 within scheme benefits.

The World Health Organization (WHO) was alerted of a cluster of pneumonia of unknown aetiology in patients in Wuhan City, Hubei Province of China on 31 December 2019. The respiratory tract infection was identified as being caused by a coronavirus, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and the illness was named coronavirus disease 2019 (COVID-19) on 11 February 2020. The following month, the WHO declared the outbreak as a pandemic 19 March 2020, a National State of Disaster was declared in Namibia.

As most health care facilities have limited resources, the scheme has limited funding. Therefore, it is essential that we work together, to ensure that the right patient, received treatment in the right facility, at the right time.

These guidelines below clarify benefit allocation for Heritage Health Medical Scheme beneficiaries within the context of the pandemic, ensuring that there is uniform interpretation amongst all stakeholders. It sets out recommendations for the screening, diagnosis, treatment, and care of individuals with suspected and confirmed COVID-19 as per WHO case definitions, based on WHO Clinical guidance and NICD (SA) guidelines.

Guidelines for consultation for diagnosis

  1. Consultation - A screening is questionnaire must be part of virtual or face to face consultation. In line with WHO recommendations to further reduce the person to person risk of transmission and reduce the number of patients at doctors’ rooms, telehealth consultation is suitable. These will be reimbursed from the members consultation benefits.
  2. Questions to be e asked by the healthcare worker during screening include:
    • Recent travel to a high-risk country (in the last 14 days)
    • Any contact with anyone with confirmed COVID-19 (in the last 14 days)
    • Any history of attending or working at a facility where COVID-19 patients were being treated
    • Any symptoms such as fever, sore throat, cough, and difficulty in breathing
    • Any underlying condition (including high blood pressure, diabetes, asthma, respiratory illnesses, systemic illnesses)
    • Any medications being taken (including immunosuppressive therapy)
  3. Patients to be tested for RT-PCR testing for COVID-19, are individuals who meet the criteria for a person under investigation, upon referral from a health care worker.

Funding of RT-PCR test

  1. The RT-PCR test are be funded from the pathology benefit irrespective of the RT-PCR result.
  2. A single positive RT-PCR test is sufficient proof of COVID-19 infection, and there is no role of repeat confirmatory test.
  3. An RT-PCR test can however be falsely negative due to factors such as sampling technique or timing of the test. If alternative diagnosis has been explored and there is still clinical suspicion of COVID-19, a motivation should be submitted to the scheme for a repeat test.
  4. According to the WHO, as of 24 April 2020, no study had evaluated whether the presence of antibodies to SARS-CoV-2 confers immunity to subsequent infection by this virus in humans. There is currently no evidence that people who have recovered from COVID-19 and have antibodies are protected from a second infection. As such the number of RT-PCR tests per member is limited but may be motivated for funding if a member presents with COVID-19 symptoms and meets the NICD case definition.
  5. Asymptomatic people should not be routinely tested. Funding of asymptomatic people are excluded. This includes asymptomatic people who are returning to work.

Management of suspected and confirmed cases with mild to moderate disease

  1. Suspected and confirmed cases who are medically well, or who have mild disease should be managed at home.
  2. All underlying pre-existing chronic conditions such as diabetes, HIV, asthma etc, should be managed accordingly
  3. Treatment and care for the management of mild to moderate disease will be funded from the beneficiary’s day-to-day benefit.
  4. Given that the scheme is notified of all positive cases of COVID-19 irrespective of the severity, medication prescribed by the doctor for COVID-19 confirmed patients will be funded from the beneficiary’s day-to-day benefit.
  5. The provider should include the correct ICD 10 code (U07.1) on the prescription. To reduce the administrative burden, and given that this is not a chronic condition, no prior authorisation is required. Generic substitution is permissible unless provider instructs otherwise.
  6. If the beneficiary has insufficient benefit, a request for clinical Exgratia may be made to the scheme for funding.

Management of suspected and confirmed cases with severe to critical disease

Benefit pre-authorisations for admissions into hospital facilities must be restricted to patients with severe to critical disease. Admission into the relevant level of care will be authorise according to clinical information provided through the daily case management updates. It is therefore requested that pre-authorisation request and case management updates include:

  1. Symptoms reported by the patient
  2. Vital signs include respiratory rate and saturation levels

Confirmed or Suspected COVID-19 patients should be discharged when clinically indicated and continue self- isolation at home if it is still required.

Billing

  1. The WHO has published ICD-10 codes to be used for the COVID-19 and Heritage Health recommends that correct coding be used to enable correct identification and reporting thereof.
  2. The surveillance for COVID-19 is essential to permit early recognition of suspected cases, early diagnosis, containment, and prevention of onward transmission.
  3. Possible ICD-10 codes for identifying COVID-19 ICD-10 code WHO description:
    • U07.1 COVID-19, virus identified
    • U07.2 COVID-19, virus not identified
  4. The ICD-10 code U07.2 includes the following:
    • Clinically-epidemiologically diagnosed COVID-19
    • Probable COVID-19
    • Suspected COVID-19

Our collaboration in these difficult times will ensure the best care and outcomes for our members and you patients.