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Electronic Benefit Management


Metropolitan Health Risk Management has developed a state-of-the-art Electronic Benefit Management (EBM) solution, which surpasses the current pharmaceutical benefit management facilities available in the healthcare market.

 

EBM sets the standard for online administration of medication claims in South Africa, allowing medical schemes to transact online with providers throughout South Africa and to administer benefits that are customised to their requirements in a highly automated environment. The system is supported by call centres to assist clients, members and service providers with administrative, clinical and technical queries.

 

Across the medical aid industry, medication expenditure accounts for a significant proportion of total benefit expenditure with the latest (2008 - 2009) report from the Council for Medical Schemes (CMS) indicating the average figure to be at 17%. It is essential for medical schemes to have adequate control over the utilisation of medication by reducing medication costs, improving clinical outcomes and transacting electronically in real time. EBM is designed to give a medical scheme full control of this process through a seamless and integrated offering.

 

Our solution is distinctly different from the other offerings in the healthcare market for a number of reasons:
  • Seamless integration enabling a single view of the patient.
  • Clinical expertise supporting the development and maintenance of the product.
  • Clinical rules-based systems for chronic, acute, self (over-the-counter) and other medication benefit management.
  • Acute to chronic conversion which is an innovative EBM tool that identifies patients or members who are claiming possible chronic medication from their acute medication benefit. This tool informs the member and advises them (as well as their treating doctor) to apply for authorisation of that medication from the chronic medication benefit. This allows proper usage of the various medication benefits in the members' best interest.
  • Integrated Formulary management.
  • Our Preferred Pharmacy Network (PPN).
  • Our Designated Service Provider Pharmacy Network.
  • Constant systems innovation.
  • Reference pricing including industry-leading Therapeutic Reference Pricing product.
  • Integrated fraud risk strategy.

For more information, please contact us using the details listed below:

 

Tel: 021 480 4485
Fax: 021 480 6861
Email: [email protected]

 

Pharmaceutical Electronic Standard Authority (PESA)

 

The PESA category list is used to manage medication claims. This is a list of 43 categories developed by the industry, and is used to identify items that a medical scheme will or will not fund from their members' acute (day-to-day) or Over-the-Counter (OTC) funds, and is based on the rules and managed care protocols of that scheme.

 

Metropolitan Health Risk Management advises the schemes they manage on which categories are appropriate to cover for members and particular circumstances. In instances where schemes wish to cover a product (i.e. contraceptive preparations - PESA Cat 1) from their acute benefit, PESA cat 1 will not be added.

 

Some items are considered inappropriate for re-imbursement within the medicine management system, and therefore will be excluded from funding. These include, but are not limited to:

  • aphrodisiacs,
  • sun screening and sun tanning agents,
  • anabolic steroids

Please note: The PESA exclusion category is determined by each scheme and may not be disclosed by Metropolitan Health Risk Management.

 

Metroplitan Health Reference (MetRef) Price list

 

Please click on the schemes below to view the relevant MetRef List: