Although most corporates and consumers make their medical scheme purchasing decision based on their awareness of the brand, benefits offered and price, the administrator plays a role in ensuring that the medical scheme is competitive, says Kevin Aron, managing director of Medscheme South Africa.
"Self-administered medical schemes are the exception in the South African market and depth of administration and managed care services provided by third-party administrators makes all the difference," he adds. Administration, for example, requires the capacity to process large volumes of complex assessing and payment transactions.
These transactions must be processed while seamlessly applying complex benefit rules and managed care protocols simultaneously, which demands both an intimate understanding of the healthcare environment in SA, and expertise in terms of the clinical, actuarial and ethical aspects of healthcare, and world-class information and communication technology. The ideal administration partner for both corporate clients and medical schemes must thus offer a superior range of services. This should be enhanced by a total commitment to providing a superior customer experience and customer centricity that adds equity to the client medical scheme brand.
"As one of SA's largest administrators and managed care providers, Medscheme is extremely well positioned to meet the specific needs of medical schemes and their members," says Aron. "Medscheme has been a leader in its field for more than four decades and this understanding of the healthcare market in SA is underpinned by customisable administration solutions and the peace of mind brought about by the knowledge that all processes are certified by the internationally accepted ISO 9001:2008 standard.
Our managed care services are also considered the industry benchmark." Aron says as a result of long-standing relationships cultivated with clients, Medscheme has developed deep insight into their strategic objectives, which equips it to provide tailor-make solutions that meet clients' objectives. Flexibility and innovation are critical to retaining a competitive advantage.
"This relates to every facet of the claims process including processing, assessing, payment, benefit and managed care rule application as well as communication, reporting and accounting," he says. "Medscheme has a long heritage of introducing industry firsts, which has become the norm. Innovations include alternative reimbursement models for doctors, the largest healthcare provider network in the country that ensures that members receive quality healthcare and the best health outcomes for the patient at a reasonable cost." He says a team of specialist healthcare actuaries are able to generate robust data management systems and analytical models, and track trends in healthcare - turning these into insightful information that directly benefits clients.
World-class information and communication technology is central to the success of medical schemes and Medscheme outsources its IT development to Helios IT Solutions, a company which specialises in developing and maintaining technology specifically designed for the healthcare industry. Medical schemes manage billions of rands of members' money and it is here that excellence in corporate governance is crucial. "Stringent internal financial controls that are aligned to King 3 and other international benchmarking exercises must be in place," says Aron.
"Similarly, with fraud costing the industry an estimated R20bn a year, it is crucial that an administrator is equipped with sophisticated systems to detect and investigate potential fraud as well as have the capacity and relationships with the authorities and police to ensure that perpetrators are brought to justice. Medscheme is a proudly South African company and as a leading administrator we remain committed to ensuring that clients and consumers can always receive excellent service and affordable quality healthcare," he adds.
Business Day, 19 June 2014
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