Challenging mindsets and developing collective solutions

Services

clinical coding services

We provide strategic and practical clinical coding and related services that include:

  • Customisation of existing healthcare intervention coding systems
  • Introduction of new and modification of existing healthcare intervention codes
  • Interpretation of existing clinical codes, rules and guidelines
  • Development and maintenance of purpose-made clinical coding groupers
  • Development and maintenance of purpose-made data specifications
  • Training on the objectives and application of clinical coding

Our services pertain to all the coding systems that are currently in use in South Africa, namely:

  • The so-called Reference Price List or “RPL” coding systems
  • The Current Procedural Terminology (CPT®) coding system, together with the South African version thereof (CCSA®)
  • The International Classification of Diseases (ICD)
  • The National Pharmaceutical Product Index (NAPPI)

The level of our clinical coding consulting services ranges from the provision of detail technical advice to broad contextual interpretations of actual situations.

clinical
reporting

We develop and prepare reports considering the clinical aspects of healthcare funding that includes:

  • Health quality indicator development and analyses
  • Clinical and associated financial outcomes analyses, including actual versus expected comparisons
  • Cost and utilisation trend analyses
  • Development and maintenance of reporting tools and methodologies

Our reports are typically custom built based upon specific user needs and, where required, we offer interpretive services and training to users to maximise the benefits to be gained from our reports.

Healthcare account
auditing and dispute
resolution

Clinical coding systems are very structured and pragmatic, but actual clinical situations often have specific circumstances and nuances that require interpretations of the codes used within the contexts of specific situations. In the absence of such contextual interpretations, it can happen that claims are deemed to be inappropriate and/or they can be allocated to incorrect benefit pools. This becomes problematic when practitioners become accused of inappropriate billing and/or patients are confronted with out of pocket expenditure.

We specialise in the contextual interpretations of individual accounts or claiming and reimbursement patterns in general and assist medical schemes, medical practitioners and/or their patients with the resolution of:

  • Potential Prescribed Minimum Benefit claims
  • Potential inappropriate application of benefit allocations
  • Disputes with respect to the interpretation of scheme rules
  • Disputes with respect to accounts rendered and/or claiming patterns in general

Interpretation
of  reports

Reports that managed care organisations contractually provide to medical schemes and medical scheme trustees can become overwhelming and intimidating.

We analyse managed care reports and offer:

  • The preparation of practical and topic-specific summaries
  • Independent interpretations
  • Suggestions on potential responses to trends observed

Feedback is provided through written summaries, presentations at appropriate meetings or both.

Development of
risk management
strategies

We are increasingly finding that schemes require risk management strategies that are or can be customised according to specific needs. Such needs may vary between medical schemes and within medical schemes between benefit options.

We work closely with medical schemes as well as their administrators and managed healthcare service providers toward finding optimal strategies within given sets of circumstances.

Development of provider
management strategies

As is the case with other risk management strategies, we are finding that schemes’ needs with respect to their relationships with healthcare practitioners and other healthcare service providers can vary and that various degrees of customisation may be required.

We work closely with medical schemes as well as their administrators and managed healthcare service providers toward finding optimal strategies within given sets of circumstances.

DEVELOPMENT AND MAINTENANCE OF CLINICAL GUIDELINES AND REIMBURSEMENT POLICIES

In instances where medical schemes do not have access to a larger pool of resources in terms of the development and maintenance of clinical guidelines and reimbursement policies, we leverage our experience and capacity to assist with the actual development and maintenance and/or to support the processes.

Smaller self-administered medical schemes or practitioner groups that are looking to enter into alternative reimbursement models and/or provider network arrangements would typically make use of this service.

Trustee
Training

We provide training to trustees of medical schemes on aspects pertaining to clinical as opposed to corporate governance. In this instance clinical governance refers to:

  • The principles that underlie clinical coding, the application of clinical coding and the various types of clinical coding in use
  • The principles that underlie clinical risk management and strategies that could be explored to achieve various objectives
  • How to read and interpret managed healthcare reports
  • The relevance of legislation with respect to clinical governance principles

service provider
contracting

We provide technical support and input toward the development of contracts and accompanying service level agreements between medical schemes and:

  • Medical scheme administrators
  • Managed healthcare organisations
  • Individual healthcare service providers and/or service provider groups
  • Individual healthcare practitioners and/or practitioner groups

We also provide technical support toward the development of tender requirements for administrative and managed care services and the adjudication of tender submissions.

MEDICAL ADVISORY
SERVICES

As registered medical practitioners we provide medical advisory services at various levels:

  • Routine medical advisory services typically supporting hospital benefit management, disease management and medicine benefit management services
  • Escalations to scheme clinical committees or appeal boards
  • Prescribed Minimum Benefit appeals
  • Appeals to the Council for Medical Schemes
  • Responses to legal challenges

Our advisory services include the review of available documentation, interacting with treating practitioners and preparation of comprehensive clinical reports including reasoned recommendations.

CLINICAL BENEFIT
DESIGN

We provide clinical technical support to medical schemes’ annual benefit review processes by actively participating in the benefit review processes through:

  • Attending benefit design committee meetings
  • Offering insights on the clinical implications of benefit designs
  • Offering independent views on the alignment between the scheme’s general strategy and associated objectives, the scheme’s clinical and financial risk management objectives and service provider proposals
  • Independent reviews of product and service offerings by risk management providers
  • Working with the scheme’s appointed actuaries during the determination of estimated impacts of proposed benefit changes and/or risk management interventions

PROFESSIONAL
ASSOCIATIONS

We offer ongoing and project-based support to professional associations on aspects such as:

  • Development and maintenance of procedure coding structures
  • Development and maintenance of internal strategies in terms of the development and growth of the value proposition offered to members
  • Supporting members that have been identified through profiling processes
  • Development of relationships between the associations and medical schemes and/or their administrators and manged care providers
  • Development of contracting principles and alternative reimbursement models

EMPLOYERS/CORPORATE
CLIENTS

We offer strategic and technical advice to employers, employer groups and corporate clients through:

  • Provision of technical input toward the development and maintenance of corporate health strategies
  • Active participations in organisational health processes
  • Working with appointed intermediaries toward the identification of the most suitable medical scheme/s within the context of the employer’s specific corporate healthcare strategy, objectives and employees’ healthcare needs
  • Interpretation of reports submitted by healthcare service providers, such as medical schemes, Employee Assistance Providers and the like
  • Interpretation of reports released by industry regulators such as the Council for Medical Schemes
  • Training and educating relevant decision-makers on industry developments, such as the potential impact of the proposed National Health Insurance plan
  • Provision of advice on the synchronisation between the healthcare services that are typically provided or procured by employers, such as:
    • Medical scheme benefits
    • Occupational Health
    • Employee Wellness Programs
  • Provision of support to individual employees with respect to the resolution of medical scheme claims queries at operational levels as well as with escalations within the medical schemes’ own structures and ultimately to the Council for Medical Schemes