Medical Services Organisation (MSO), the hospital benefit management business, has made it possible for medical aid administrators to perform hospital benefit management themselves.
MSO and software house MIP Holdings have developed a system named MedCap, investing almost R20 million, to enable this.
"We needed a system to support our own requirements in 1996 and investigated a US system, but it did not suit the local market and changes would have been too significant," says Diane Pennels, clinical and technical systems director at MSO. "We discovered MIP`s MedStar system, which had much of the functionality that we required and we altered it to suit our business. We have now arrived at a solution, working with MIP, that is suitable for the local market and we already have 11 clients."
MedCap has been developed using Progress Software`s 4GL database and development software and runs on a Sun Unix server at MSO.
The system supports the three major components of managed care: namely preauthorisation of hospital services, case management and clinical audit.
"The key to the success of this system has been its ability to evolve alongside industry changes. Initially it was designed as a capitation module, but because it is so flexible it has grown to fulfil our and our clients` needs for hospital benefit management," says Pennels.
The clincher for MSO in choosing MIP was its experience in the medical industry. The company`s systems service over 700 000 principal members, with systems spanning medical aid administration, managed healthcare and sectors of the financial services industry.
"The industries we currently target with our applications are the pension, medical aid and life assurance administration markets or any business collecting a contribution and paying a benefit," says Don Elliott, sales director at MIP. "Our applications take on the day-to-day running of administrators` businesses."
Pennels adds: "Although it is a clinical system it is based on a financial core. Recent development accommodates multiple tariffs for different service providers as well as an electronic data interface for hospital claims and alternative re-imbursement structures."
She says the system automates much of the authorisation process and it incorporates most of the decision-making involved in medical claims using a -based procedure.
The primary benefit of the system is its ability to cope with clinical and financial changes. Pennels says the industry will always deliver the same type of medical treatment, and major changes are primarily financial. "You will get the same treatment, but the way you pay for it will be different," she says.
The system is managing in excess of 270 000 members through MSO`s insource and outsource clients. That figure was attained in 18 months.
A future development is to incorporate online member integration with MSO`s schemes. "The value of real-time interaction is in membership verification and we are in the process of developing it," says Pennels.
For those customers that house their information on servers at MSO, as well as for its own information store, MSO performs daily backups with disaster recovery in that it maintains a full copy of the database at MIP`s office. "This is our business and we cannot afford the system to go offline. In that regard MIP has given us all the consulting support that we required to ensure business continuity," Pennels says.
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