Medscheme’s Hospital Benefit Management (HBM) focuses on mitigating financial risks associated with the intensity (what happens in one day) and severity (what happens over a period of time) risks. We therefore:

• review and authorise appropriate requests for benefits to registered facilities,
• ensure that members are treated by registered and appropriate providers, and
• ensure that members receive acceptable forms of treatment at appropriate levels of care for a reasonable length of stay.

Pre-authorisation of hospital admissions and out-of-hospital care is a key component in managing access to affordable, appropriate, safe and quality health care. Medscheme’s pre-authorisation requests are adjudicated against clinical and funding guidelines as well as set criteria in recognising healthcare providers who are able to perform certain procedures.

While a patient is in hospital, our case managers will ensure that the appropriate level of care is provided at all times, and that appropriate discharge planning takes place for optimal member recovery and clinical outcomes.

Our clinical audit and re-pricing of claims process ensure that legitimate claims are paid against the contracted hospital rates and the authorised admission. And our member-centric process provides a single entry point for members to contact Medscheme for administrative support and hospital pre-authorisation (pre-certification).

Medscheme also focuses on member care co-ordination by improving the quality of care for members through the efficient and effective use of available resources. The power of this sits in the sharing of information about a member’s condition, well-being and health within different managed health care departments as well as with the member’s doctor. Co-ordinating the member’s care is done through the following interventions – from pre-admission to eight weeks after they are discharged – in order to ensure best health care; reduce re-admissions and encourage members to take responsibility for their own health:

• Targeted telephonic contact with a member before they are admitted.
• Distribution of a pre-admission hospital checklist to prepare the member for hospitalisation and post discharge recovery.
• Post-discharge follow-up telephonic contact by clinical agents and assessment of important health parameters.
• Referral to various managed care services and appropriate healthcare providers as and when needed.

Our specialised case management team has a dedicated focus on psychiatric cases, neonates, high cost cases and cases where alternatives to hospitalisation (e.g. step down facilities) can be utilised.

Did you know?
Case management has both an immediate and long-term impact. It ensures appropriate management and appropriate treatment of a member before they are admitted to hospital during their hospital stay and even after they have left. We also educate the member on their health. In this way we improve member outcomes and reduce the likelihood of re-admission to hospital.