HEALTHCARE CLAIMS ADMINISTRATIONThe changing landscape of healthcare requires a dynamic partner that can add value

Insurers and other healthcare funders require a delivery partner that understands the relationship between the client and their members and can deliver consistently on service level agreements. The accurate and timeous payment of claims to the correct providers is only a part of what a third party administrator should deliver.

The following gaps in claims administration results in lack of meaningful reporting and management capabilities: •Inadequateprocedureanddiseasecoding •Poordataintegrity,weakdata structures and limited analysis capability •Poorfraudmanagement •Limitedautomation

Our seamless and efficient processes allow for massive transaction volumes capability and we make use of innovative technology to contain your administration costs, whilst enhancing members’ experience.

KEY BENEFITS

We are a healthcare claims administrator with more than 40 years of experience. Our service is underpinned by ISO accredited processes,highlyskilledprofessionaland administrative staff supported by an integrated technology infrastructure. Medscheme supports its clients through:- A client-centric business model that aligns to each scheme’s uniqueculture,objectives and strategy. - A depth of institutional knowledge which enriches and empowers our continual business process enhancements. - A powerful IT infrastructure that seamlessly and efficiently processes massive transaction volumes and makes use of innovative technology to enhance the customer experience.- Regular electronic updates to members on claims status via email/sms/web.- A company that thrives on delivering service excellence.

HEALTHCARE CLAIMS ADMINISTRATION - VALUE PROPOSITION

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MEMBERSHIP MANAGEMENT - DESCRIPTION

05 Payment instruction

5.1 Static – payment runs at defined intervals (twice weekly, fortnightly or monthly)

5.2 Dynamic – payment runs to rectify specific problem areas Needs development, we do not have capacity with current system limitations

5.3 Member and health-care professional statements

5.4 Member contact centre (optional)

01 Claims management and administration

1.1 Electronic claims receipt via real time, batch, email or fax

1.2 Paper claims are scanned/imaged and indexed and then processed

03 Benefit rules engine

Electronic application of clinical funding protocols

04 Benefit validation

Availability of benefit limits as well as the applicability of co-payments and excesses as per scheme rules and legislation.

08 Reporting

8.1 Standard and customised business intelligence reporting

8.2 Financial and other supporting reports

8.3 Fraud reporting

07 Claims administration technology platform

7.1 Real-time interfacing and processing of transactions

7.2 Intelligent, real-time communication to members and health-care providers

7.3 Highly parameterised functionality and customised client set-up.

7.4 Disaster recovery capabilities

7.5 Data warehouse

02 Validation of claims

2.1 Claims are checked for the correctness and appropriateness of tariffs, diagnostic and procedure codes (e.g. ICD10), completeness and format of claim, matching

2.2 Pre-authorisations (which include application of waiting periods and exclusions) are compared with the incoming claim. This includes matching to the Level of Care authorised as well as clinical audit of medicine items billed or any special circumstances linked to the specific authorisation.

2.3 Membership validation, e.g. member number corresponds with name, is a valid number and membership is active.

2.4 Practice validation, e.g. practice number correspond with authorisation, is a valid number, and if the practice is linked to any provider groups, that the correct fee schedule has been billed according to any particular agreement.

06 Quality assurance

6.1 Claims turnaround times are measured in terms of dates claims are received, processed and paid. Claims processing accuracy is enhanced through a high degree of automated processing, built-in audit functionality and modular systems integration.

The Quality Assurance department monitors the accuracy of claims processing by performing the following functions:

• Randomsamplingofclaimsprocessed per employee per month

• Statisticalformulatakingintoaccount historical error rate and degree of certainty

• Qualitycriteriafocusedonerrorsaffecting payments and quality service

• Erroranalysisincludedintofocused staff training

• Staffincentivestoachieveazeroerrorrating

6.2 Comprehensive claims history is used in claims validation and duplicate checks

6.3 Detailed and accurate claims statements

6.4 Management of specialised claims such as ex gratia, third party claims.

Sustainable health-care = cost risk management + outcomes improvement

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MEMBERSHIP MANAGEMENT - PRODUCT WORKFLOW

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Fina

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Repo

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Claim coding

Data validation

Ongoing operational reporting

Claims provisioning

Fraud

Static payment runs

Payment runs

Clientcommunications

Member payments

Processing accuracy

SLA compliance

Rule engine

Care protocols

Decline

Benefit validation

Guarantee of payment

Providercommunication

New Claim

Membership platform

Claims department

Financial department

QA department

• Web• Post• Email

• Mobile• Fax• EDI

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MEMBERSHIP MANAGEMENT

www.medscheme.com

Office Line: +27 11 671 2000E-mail: Partner@medscheme.co.zaHead office: 37 Conrad Road, Florida North, Roodepoort, 1709Postal address: PO Box 1101, Florida Glen, 1708

Medscheme Holdings (Pty) Limited Reg No 1970 | 015014 | 07

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