How Does Managed Care Help South Africans?

Managed care is an entity that medical insurance organisations and medical schemes have introduced. It controls the cost of medical care for their members in the face of increased claims and medical practitioner fees.

Managed care is a way of ensuring that contributing members get the medical service most commensurate with their contribution. In this way, the medical insurance entities have introduced measures to control the nature and amounts on claims by contributing parties. Therefore, this process involves the insurer assessing claims submitted against contributions made and deciding how much they will cover. In this way, the insurer takes control of medical procedures for their members.

Where does Managed Care Begin?

Managed CareThe process of managed care begins when the member puts in a claim for hospitalisation. So the scheme will have to authorise the member before admission into the hospital for the procedure. And this may involve even recommending home treatment or an alternative hospital.

Upon admission, the member’s account is assigned a case manager. Who works with the doctor and hospital staff selecting ideal options commensurate with contributions. Following this, the case manager will assess all medical bills submitted and prescription medication to guard against fraudulent charges. So they will ensure that all treatment received will incorporate an aspect of training. To empower the member to avoid a more costly procedure in future.

Fragmented medical fraternity

Because the South African medical fraternity is so fragmented, it resulted in patients at times being referred for unnecessary procedures and being billed for cosmetics they did not need. As such managed or coordinated care helps to control these aspects and ensure that the industry sticks to the bottom line. In this way, medical insurers aim to make sure that patients get exactly what they need at the right price. The act of managed care, however, requires that case managers get access to patients’ personal medical records. As they work toward creating the ideal solution for the member.

Managed or Coordinated care treats members as a holistic individual and therefore aims to impact all aspects of their life to guard their well-being. As such the programme will enrol the member into training courses that aim to change their life and hopefully circumvent the possibility of medical treatment.

Managed care works based on certain controlled factors. Such as management of the high-risk beneficiary scheme which is to control the rate at which high-risk members claim for medical insurance. Secondly, the consolidation of general medical practitioners to ensure early treatment of general illnesses at very affordable fees. Lastly is the access to; management of; and sharing of patients medical records. That leads to better healthcare for the patients.


All info was correct at time of publishing