Agility Health and Medical Aid Responsibilities

Medical aid members pay a huge monthly fee each month so that they can enjoy superb medical care. But what is happening to the premiums they pay each month? After all, medical schemes have a responsibility to manage the funds of their members properly and to safeguard them. That is what medical scheme administrators like Agility Health are for.

Agility Health CEO Patrick Masobe

Patrick Masobe

Patrick Masobe, CEO of Agility Health, looks at methods used to assess the long term sustainability of medical schemes.

What is Agility Health?

Agility Health believes that administration and managed healthcare delivers proper risk management of the medical scheme. South African medical scheme’s enjoy the benefit of unmatched administration and managed care services from Agility.

Agility Health is a subsidiary of Agility Holdings. That is one of the biggest open medical scheme administrators in the South African healthcare industry.

Agility Health uses software to support managed care and administration of medical schemes. This is an embedded software component of an application. It apples a set of guidelines based on the needs of the South African health system. Medical experts from various fields developed the system.

Agility Health System

This amazing system has attracted interest, and the guidelines embedded in the system have even proved their worth internationally. Masobe says that they have even exported this intellectual property to many countries abroad.
Historically, the South African market involved traditional options that provided particular benefits for their healthcare needs. Members would for example have R2 000 for dentistry, have 4 general practitioner visits and so on.

Agility HealthBut what about those members who wear dentures for instance and never ever visit a dentist? Why should they be paying R2000 for dentistry benefits when they don’t require much treatment?

This sort of query led to the introduction of the savings-based option. Here members have freedom of choice when it comes to their day-to-day healthcare needs. This is the role of Agility Health – to protect the well-being of the medical scheme members. And also the financial health of the scheme.

Prescribed Minimum Benefits a Headache

Masobe went on to explain that their systems are can detect over-servicing excellently, so that they can rein in wastage without taking away in any way the care that members require.

He went on to say that this was particularly important with Prescribed Minimum Benefits. By law, medical schemes must cover these. PMBs are still a matter of concern for the sustainability of the industry, especially since the scrapping of the NHRP or National Health Reference Price List.

Claims for these PMBs aren’t a blank cheque, so it is important to have systems in place to detect claims discrepancies.

A concern within the industry is these Prescribed Minimum Benefits (PMBs). Of all the complaints that medical schemes under administration by Agility Health have to deal with are PMB-related. ICD10 codes and their incorrect usage is also part of these difficulties.

Abuse, fraud and claim discrepancies within medical schemes is busy crippling the industry and there is a need for investigative services to tackle this fraud and wastage. Certainly, fraud represents a threat to the sustainability of medical schemes.

New Generation Medical Schemes

Today most schemes offer a combination of  new generation and traditional options. However, ever increasing healthcare costs are having an impact on both medical schemes and their members.

Increasing healthcare costs, combined with the Council for Medical Scheme’s 25% reserve requirement, represent a huge financial load for medical schemes.  For medical aid members, most of the medical schemes also announced high 2017 contribution increases in an effort to replenish reserves.

Even though medical schemes operate as a non-profit, it is their responsibility to provide for their members’ healthcare needs, regardless of whether they face unusual spikes in claims or not. The 25% reserve requirement was first part of a larger infrastructure of factors so as to support the viability of the medical schemes industry.

Many of these other factors have fallen away with a scheme’s reserve percentage being the indicator of its long-term sustainability.

Masobe says that health care fraud is a huge economic drain, and all it does is raises costs for insurance companies, which in turn increases medical aid premiums for everyone.