Section A: Fees for Admitted Patients

7. TAC Patients

7.1 Invoicing TAC for Activity

The arrangements for the provision and payment of a range of public hospital services for TAC patients are outlined in Circular 04/2008.

There are no major changes to the payment processes in moving from the original to the renewed arrangements. DH continues to receive funding directly from the TAC for WIES funded separations. DH in turn continues to cash flow hospitals accordingly. Separate uncapped TAC WIES targets have been incorporated into hospital budgets, based on prior year throughput reported in the VAED. All other payments are reimbursed directly by TAC.

For more information, please visit the Transport Accident Commission (TAC) website.

7.2 How the payment process works

For DH to receive payment from TAC, TAC must accept the claim and issue a claim number. The patient information reported by the hospitals to DH via PRS/2 must match exactly those held by the TAC for each admitted patient separation. Details of the new data elements required to assist in this process are published in the Specifications for Revision to PRS/2 and to the VAED as updated at Health Data Standards & Systems (HDSS)

The department will pay a rate applicable for all accepted TAC patients matched with TAC records (as reported in the VAED) including numbers in excess of the published target. If hospitals do not achieve the TAC target, any funding which has been cash flowed will be recalled at the full TAC rate. It is imperative that hospitals ensure that their own records are complete, comprehensive and timely.

Hospitals should only accrue revenue for accepted TAC records. Any rejected records will be automatically funded as public in the prior year adjustment (PYA) process, up to the agreed public or private WIES target.

Hospitals should ensure that TAC records are updated in the PRS/2 with monthly information fed back by the Department.  This will ensure that updated records will be accepted by TAC and therefore minimise delays in reconciling activity and payment for records with TAC.

Errors that are not accurately corrected by health services, such as a patient’s data of birth, continuously cycle through both the DH and TAC databases and remain unmatched and as a result unfunded. This causes additional review, reconciliation and problem solving by the TAC and DH. Hospitals are required to ensure that information is keyed in with a high level of accuracy to prevent future errors and be proactive in identifying and remedying anomalies prior to sending data to the DH.

Patients are required to request and complete a TAC claim form by calling 1300 654 329. Hospitals should make themselves aware of the form’s specific requirements. Where hospital data does not exactly match the details a patient has entered on a TAC claim form there will be significant delays in payment from the TAC as both TAC and DH will be impacted by the reconciliation processes.

Monthly status reports to hospitals include:

• A monthly report which includes all NEW claims and any claims with a status change since the previous month
• A year-to-date update report on all outstanding claims, including those held and/or denied.

The reporting format includes the WIES value for the agreed claim and the amount paid by DH on this basis. DH remuneration rates per WIES are shown in Table 1. All hospital payments by DH will be reconciled with the actual WIES as agreed by TAC. Reports also include the following headers.

TAC Status Codes Ready Reckoner (MS Excel File 52kb)

For records where claims are not accepted by TAC, either:

• Additional information is required to be transmitted by hospitals to allow the claim to be accepted, or
• Hospitals retrospectively reclassify these patients to reflect any changes in Care Type and the preferences indicated by the patient on the form of election for admission.

Hospitals are expected to review rejected claims promptly and revise and resubmit claims if further information is required. Where there is no further recourse to the TAC these records will be designated as denied on the monthly report. Hospitals should recode these separation records as public.

As TAC claimants have 12 months to lodge a claim with the TAC, following the end of each financial year, any resulting hospital funding adjustments will be undertaken through the PYA process. This will generally only apply to hospitals that are over target, since hospitals below target will automatically be funded up to target for outstanding records, as public WIES.

Ultimately, care in data entry will significantly improve and streamline the reconciliation process.

To assist hospitals in understanding the data exchange and payment process a process map has been prepared and made available for downloading:

• Patient, Hospital, DH Process Map for Data Exchange & Payment (PPT file 1.2Mb)
• Patient, Hospital, DH Process Map for Data Exchange & Payment (PDF file 345Kb)

For issues regarding rejection or hold-up of claims contact:

Metro Hospitals
David Seinfeld: email david.seinfeld@health.vic.gov.au or Dominic Fama: dominic.fama@health.vic.gov.au

Rural Hospitals
Teresa Guerrieri: teresa.guerrieri@health.vic.gov.au

7.3 TAC Payment Overview

WIES funding for TAC admitted patients in public hospitals and separate trauma related specified payments continue to apply. TAC WIES throughput is uncapped. All admitted and non-admitted prices will be adjusted annually

Reference Circular No 4/2008

Hospitals will continue to receive WIES throughput and trauma specific payments for TAC patients from DH. Hospitals, however, will need to continue to charge TAC directly for the specialist medical and imaging costs associated with these admitted patient episodes, rehabilitation and non-admitted patient services.

WIES will be paid at the TAC specific payment rate shown in Table 1.

The rehabilitation 1 and rehabilitation 2 rates will be paid at the TAC specific payment rate shown in Table 2. All other admitted patient services will be paid at the public rate.

Patients may only be coded to rehabilitation care types in accordance with the Department's Victorian Admitted Episodes dataset (VAED) specifications as set out in the VAED Manual (also refer to specification changes to the manual; see Victorian Admitted Episodes Data Set (VAED))

The department will provide a Trauma Appropriateness Payment (TAP) to both Regional and Metropolitan hospitals that transfer major trauma patients directly to a Major Trauma Service (MTS).  The TAP payment rate is shown in Table 4.

The following are published in the Victoria - Public Hospitals & Mental Health Services Policy & Funding Guidelines

• Definitions for inliers and outliers for TAC admitted patients
• Cost weights and related parameters for TAC admitted patients.

7.4 TAC Patient Types

7.4.1 Acute admitted patients

TAC compensable patients should only be admitted to hospital in accordance with the Minimum Criteria for Admission as specified at DH Hospital Admission Policy - Effective 1 September 2008 (PDF File 92KB)

New Admission Policy

Fees for TAC compensable separations (Table 1) are based on AN-DRGs with Victorian modifications (VICDRG) and the Victorian DH cost weights.

The formula for calculating weighted inlier equivalent separations is the same as the general hospital casemix funding formula set out in the Victoria - Public Hospitals & Mental Health Services Policy & Funding Guidelines 2008 - 2009.

For acute episodes of care, the payment rate for TAC separations is per Weighted Inlier Equivalent Separation (WIES).

7.4.2 Emergency Department (ED) only attendance fee

7.4.3 Rehabilitation patients

Fees may be raised for TAC compensable patients admitted for same-day rehabilitation for provision of same day treatment. Criteria for admission as a same day admitted patient are that the patient:

• Attends a rehabilitation program designated for payment purposes by the Department, and
• Attends for two or more therapy interventions, and
• Receives treatment for a period of four hours or more.

Where the criteria are not met, the fees raised for attendance for rehabilitation would be in accordance with the appropriate non-admitted patient fee rate.

Fees for patients separated from Designated Rehabilitation Programs are paid at the rate specified in the DH payment schedule (see Table 2). The Department’s VAED Manual lists Designated Rehabilitation Programs for the purpose of Care Type 2, 6 or 7. Also refer to specification changes to the manual; see Victorian Admitted Episodes Data Set (VAED)

The rehabilitation rate is per bedday.

7.4.4 Other Admitted Patients

Fees for other separated patients are paid at the rate published in the Policy and Funding Guidelines. Payment rates for other admitted patients are summarised at Table 3.

7.4.5 Trauma Patients (TAP)

The TAP is in part recognition of the financial impact on public hospitals that refer and transport trauma patients to Major Trauma Services (MTSs). For more information on the Trauma Appropriateness Payment (TAP), see www.health.vic.gov.au/trauma/tap.htm. The TAP payment rate is shown at Table 4.

7.4.6 Other TAC Patient Types

Payment rates for non-admitted patients in specialty clinics and mental health, diagnostic imaging and medical reports are shown in Tables 5-7 respectively.

Payment rates for medical and allied health services in outpatients, casualty and accident and emergency are shown in Section B: Fees for Non-admitted Patients.

7.5 Payment Rates

Table 1 WIES Payment Rates

Table 2 ED only attendance fee

Table 3 Rehabilitation Payment Rates

Table 4 Other Inpatient Fees

Table 5 Trauma Appropriateness Payment Rates (TAP)

Table 6 Non-Admitted Patient Fees

Table 7 Diagnostic Imaging Fees

Table 8 Medical Reports Fees

7.6 New hospital resource section on the TAC website

The TAC has developed a Hospital Resource section for all hospital staff working with TAC clients, so that you may now easily access information regarding:

• Clinical justification
• Commonly used outcome measures, guides to selecting and using outcome measures, case examples
• TAC claim lodgement
• Discharge planning
• Form downloads
• TAC policies
• Fee schedules

To access this new resource go to www.tac.vic.gov.au, select “Provider Resources” and then the “Hospital Resources” tab on the website. It contains links to relevant TAC policies and the TAC’s expectations in regard to the provision of hospital based services.

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