Benefit and Risk

The overall focus of the Benefit and Risk department is on minimising risks to which schemes are exposed in providing benefits for their members. It ensures that benefits are designed, worded and coded in such a way that there is little or no opportunity for misuse or abuse.

Three panels support the work of the Benefit & Risk Department: the Clinical Advisory Panel (CAP), the Coding and Hospital Panel (CHEP) and the Criteria Committee.

The CAP researches and compiles funding recommendations relating to:

  • Drugs and related substances
  • Investigations and diagnostic tests
  • Equipment and hardware
  • Evidence-based clinical guidelines for old and new therapies.

Recommendations emanating from this committee would be regularly reviewed and updated and provided as guidelines to schemes to assist them in offering greater consistency in benefit design and claims adjudication, as well as to assist members to understand the limitations of less expensive options.

The CHEP focuses on specific problems with hospital codes and descriptors, the consumable (non-chargeable) list and new equipment billing practices. It also examines hospital "baskets" for theatre time, ward days, maternity and the like and the development of a zero-based costing document for these fees. While the focus of this panel is on hospitals, they also attend to the schedules of other disciplines.

The Criteria Committee examines requirements for facilities to qualify for PCNS allocation. In consultation with various professional associations, it also gives guidance to schemes about applicable tariff codes chargeable by different categories of facility.

Strategically the department is moving towards initiatives to create more value for medical schemes. The implementation of managed care will become a focus, particularly in assisting medical schemes to determine issues such as surgeons' qualifications, the relative benefits of one surgical method as opposed to another, guidelines for the use of therapies relative to side effects, cost, age of patient and the like. Recommendations and guidelines which reflect industry standards need to be established to enable medical schemes to make informed decisions for each individual case.

The strategic focus for this department for 2006 is as follows:

  • To provide input into the NRHPL and to monitor the impact to schemes on:
    • Oncology tariffs
    • Radiology tariffs
    • ICD 10 Coding
    • Prescribed Min Benefits (Industry Standard Guidelines for 25 Chronic PMB's, Obstetric Care)
    • Theatre/Ward Baskets
    • New equipment formulas
    • Orthotic and Prosthetic Tariffs
    • Mid-year tariff adjustments
    • Consultative vs Procedural Services
    • Unbundling
    • SAMA-CPT conversion: cherry picking
    • Removal of Rule C
    • Low flow anaesthesia
  • To compile the following guidelines for schemes:
    • Tariff Interpretation Guide
    • ICD10
    • Dispensing vs Administering medicine
    • DSP Framework
    • Super-speciality accreditation
  • To work on a standardized set of guidelines for minimum care for 25 PMB's (consultations, investigations, ancillary) to assist schemes. Examples of this would be that the basic level of maternity care as PMB would be midwife delivery (unless referred by midwife to obstetrician), or where a provider is unwilling to sign a DSP agreement, the maximum liability of scheme should be NRPL if member has no reasonable alternative (i.e. provider cannot balance bill member).
  • Super Specialty Accreditation - to limit certain procedure codes to practices with training and accreditation in these procedures.
  • This has already been put in place for anaesthetics, but is still needed for the following: Neuro-intervention procedures, Cardiac catheterization, Laparoscopy and Endoscopy.

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