Managed healthcare services are on the increase as a result of the need to control spiralling medical costs and abuse of medical aid funding.
While many schemes have their own internal managed healthcare departments, many are outsourcing all or parts of this aspect of their business to companies such as Medical Services Organisation (MSO). MSO, a subsidiary through Healthcare Management Holdings (HMH) of SA Druggists, operates in this competitive arena and is the third largest managed healthcare company in the country. It manages 620 000 medical aid members and dependants for schemes such as Northern Medical Aid, IFM, Malcor, BP SA and Fedsure Health. Its pre-authorisation department takes 2 200 calls a day and authorises medical treatment worth R22 million a month. It employs 80 qualified medical practitioners including nurses and doctors to answer calls from medical aid scheme members.
To manage and process their administration, MSO needed a complex system that could cross-reference and drill down from patients` files to service providers` files and vice versa. When MSO started operating three years ago, no suitable off-the shelf system existed, but medical aid software specialist MIP Solutions could offer a solution. MIP redeveloped its existing MedStar system, now renamed MedCap, to meet MSO`s needs.
"We needed a system that linksed the records of each medical aid member`s history, and a tracking device to keep tabs on service providers, right down to individual doctor level within an institution or practice," says Kevin Aron, MSO`s chief operating officer of MSO.
Like MedStar, MedCap is based on the Progress database. At MSO it runs on a Sun server and is networked to 100 users including 40 off-site via a TCP/IP network and Diginet line. Key features include a pre-authorisation module that allows MSO to capture, in fine detail, the authorisation process for any medical procedure required by a patient. The case management procedure for each patient is initiated from this screen.
A separate but integrated module manages MSO`s interface with service providers such as hospitals and clinics.
A contracts module enables MSO to manage individual contracts with each of its service providers down to the level of negotiated fee for service. Functionality related to the contracts module includes the ability to include or exclude service providers from a network, and the ability to identify individual providers such as a specific doctor in a group practice. "This is important when you want to profile the doctors to find out who is over-servicing. It becomes a key element of managing preferred provider contracts," says Aron.
"MIP also wrote a special clinical audit module that automatically picks up medical aid abuse such as billing by hospitals for use of equipment they do not possess. An example would be a hospital charging for an angiogram when it does not have an angiogram machine," says Diane Pennells, GM of MSO. The system is able to interface with providers and medical aids` databases and exchange information. "Pressure on our call centre was recently reduced by the integration of an automatic fax file server that batches all authorisations done during the day and faxes them out at night when the call centre is closed," says Pennells. "This opened telephone lines for incoming faxes from client members and reduced our phone bill."
MSO plans several additional enhancements to the system in the year ahead. The current ACD system has been extensively improved with the purchase of an Alcatel PABX and call centre. A voice recording system linked to the MedCap system is also expected to improve efficiencies. In addition, MSO is investigating an Internet interface to enable service providers to update its files regarding authorised patients admitted and discharged on a daily basis. This will further reduce the burden on the call centre currently taking these calls.
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