Telemed Managed Healthcare Organisation has completed the second phase of its MedStar medical aid administration solution roll-out. This opens the door to implementing the range of enhancements the company has on the cards for the system.
These include deploying the Web components of MIP`s solution and constructing an online interface into provider systems, allowing remittances to be performed across the Web, exporting data for reconciliation and interfacing with the claims document scanning and management system.
"We are poised to substantially grow our market share with the roll-out of the enhancements we plan for the system, and recently securing the Eskom contract has shown that customers are already responding," says Andre de Lange, IT manager at Telemed.
"We expanded the business during the roll-out and have capacity for further growth, without increasing the burden on staff and without hiring new employees."
Telemed, originally established to administer Telkom employee needs, became an open scheme in 2000. Since recently securing the Eskom contract as preferred supplier, it has seen its principal members grow to more than 26 000, with over 60 000 dependents.
"MedStar has improved our internal efficiencies in terms of claims processing and contribution management," says De Lange. "It has also ensured that Telemed retains its competitive-edge by taking advantage of the latest technology available to fund administration systems."
Initial results of the system have seen a reduced rate in dropped calls at the call centre. This is attributed to reconciling claims in a week or less, whereas in the past it took two weeks. The call centre has capacity for 18 employees, but with currently only eight it is running smoothly.
Fraud has been reduced through validation the system performs throughout the claims process because Telemed operators are now able to capture and quickly cross-reference more information than ever before, interacting with the system in real-time. Deploying CorVu, MIP`s business intelligence tool, has enabled that.
Through its comprehensive Web interface, MedStar will enable Telemed to provide its customers with the following Internet-based services:
* Employers will have access to update employee information online;
* Brokers will have access to the underwriting process for potential members;
* Members will have the ability to conduct benefit and remittance enquiries, as well as update their personal information; and
* Medical service providers will have access to benefit and remittance enquiries, will be able to update practice information and carry out online pre-authorisation procedures.
The complete medical aid administration system offers an end-to-end solution to meet increasingly complex legislation requirements. Its modules allow for capturing, storing, updating and processing key data on health plans, members, providers and reimbursement structures.
These modules interact with each other to verify member eligibility and coverage of care, authorised services, adjudicate claims, issue payment cheques and, finally, manage member contributions.
Telemed implemented a US-developed capitation system in 1997, but found that the solution was not suitable for the local market. In a capitation system the medical aid organisation pays doctors, specialists, groups of doctors and hospitals a fixed monthly fee for each patient assigned to them. De Lange says the capitation environment did not meet the needs of Telemed`s members and that the scheme decided to return to a "fee for service" system.
Telemed opted to implement MedStar following a gap analysis undertaken by the company to determine the shortcomings of its existing information solutions.
"We mapped our IT systems to that of several technology service provider offerings in the market," says De Lange. "Once we had received responses to our requests for information and due diligence questionnaires, we consolidated the information and made our selection.
"MIP`s solution was the most competitively priced compared to other vendors. The fee to MIP is based on a per principle member per month basis and compares favourably with Telemed`s current costs. The saving incurred by implementing the system is good news for Telemed`s members and will reflect positively on the scheme`s ongoing endeavours to achieve lower administration costs.
"Another advantage is that we had been using a previous version of MedStar prior to implementing the capitation system, so our users were already familiar with the system. This also means that the data conversion operation to MedStar will be seamless, as we will be cutting back to our original version."
De Lange notes that MedStar offers many advantages to service providers because of its electronic payment functionality, which ensures that they receive payments on time, rather than having to rely on the postal system. Another benefit is the flexibility of the open systems environment, which facilitates integration with other systems including clearance houses, Telemed`s Exsol scanning system, and the Scheme`s call centre environment.
"We are keen to continue working with MIP because it is a South African company and we are committed to supporting local business development," says De Lange.
"MIP`s focus in the healthcare arena is on helping healthcare funders and service providers re-engineer the way they operate," says Don Elliott, MIP Holdings marketing director. "MedStar provides a practical solution for theoretical problems that plague healthcare funders and does away with the opportunities for fraudulent service providers and fund members to abuse schemes.
"MedStar`s integrated workflow and control systems funnel processes and procedures to enable effective healthcare management by ensuring that each step in the procedure trail can be audited and approved to ensure that members get the best service at the best price."
The system is hosted on a Solaris platform on a Sun Fire V880 server at the company`s headquarters in Germiston.
MIP provides selected outsourcing services to Telemed, including operations support (backups, batch-runs and system administration), development, maintenance and enhancements to the MedStar and Dynamax systems, and training during the implementation and post-implementation period.
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