What is Medscheme?
Medscheme offers medical aid administration and health risk management solutions to its clients. Significantly that includes both medical aids and large corporates.
Significantly, Medscheme is the largest provider of health risk management services in South Africa. Also it is the second largest medical aid administrator.
Medscheme aims to help in delivering sustainable healthcare. So this overarching vision allows it to deliver on its priorities, which include:
- Improving affordable healthcare
- Partnering closely with healthcare providers and medical aids
- Carefully examining tiered plans by measuring quality and costs of care and
- Encouraging members to manage their own health
Medscheme Health Risk Management
Firstly, Medscheme aims to work with patients and healthcare providers, thereby ensuring the best outcomes for patients with the best use of available resources. Importantly the company focuses on the following key areas to achieve this aim:
- Healthcare Providers: Medscheme has instituted the following networks of healthcare providers. Therefore they ensure cost efficiency and consistent quality of care:
- Family Practitioner Network: 5500 participants who charge medical scheme tariffs, then these are measured against set targets
- Specialist Network: 3600 specialists across all disciplines
- Hospital Networks: various networks that ensure consistent standards of care
- Pharmacy Network: 1800 pharmacies that charge a set dispensing fee and offer generic alternatives
- Dental Network: dentists contracted to charge set tariffs and
- Optometry Management Programme: cost effective eye-care
- 2. Hospital Benefit Management: coordinating patient care to ensure best possible healthcare and to mitigate financial risks through the following interventions:
- Reviewing authorisation requests against set criteria
- Ensuring treatment by registered and appropriate healthcare providers
- Ensuring appropriate levels of care and treatment
- Case management before, during and after treatment
- 3. Disease Management: finally managing high risk members and oncology cases through:
- Beneficiary Risk Management – Identifying members with chronic conditions and high risk of hospitalisation and coordinating their care and
- Oncology Disease Management -Ensuring members access funding for oncology therapy and supporting members with advice and information
- 4. Pharmacy Benefit Management: ensuring treatment is available within specific guidelines relating to chronic medication,but excluding medicines and Prescribed Minimum Benefits.
Medical Aid Administration
Secondly, Medscheme partners with medical aid administrators and, therefore, the company offers support to ensure they can deliver a quality service to their clients, thus underpinned by the following fundamentals:
- Integrated team approach: all stakeholders work together to fulfill each scheme’s mandates
- World-class technology: Medscheme outsources its technology to an industry expert and supports it with call centres and web-based self-help facilities.
- Corporate Governance excellence and
- National Branch network: 12 branches throughout South Africa
In addition, Medscheme provides solutions to many well-known medical schemes, including the following:
- Barloworld Medical Scheme
- Nedgroup Medical Aid Scheme
- Old Mutual Staff Medical Aid Fund
- SABC Medical Scheme and
- South African Police Service Medical Scheme (POLMED)