Mediscor Workshop Presentation 11 August 2010
Content 1. Profile overview 2. Our services 3. Unique capabilities 4. Conclusions Presented by: Christo Rademan - Managing Director
Mediscor Profile Overview
• An organisation specialising on the management of medicine benefits • Experienced - was established in 1989 and has been in business for 21 years. • An independent company with 124 staff members • Shareholders comprise Management and Pan-African Capital Holdings • Empowerment credentials - Empowerdex scorecard of 66 points or Level 4 contributor
• 1 st Unconditionally accredited Managed Care Organization (no MC01) • Sustainable – Is contracted to 38 medical scheme and 4 capitated clients, through 17 administrators • Large member base – manages 1.5 million lives under exclusive contracts • A broad client base – future not dependant on a single client
• Growing - Mediscor gained 36 medical scheme clients during the past 9 years • Processes > 100,000 real-time pharmacy and >30,000 doctor transactions daily • Contracted with a 100% of pharmacies • Namibia – full service at all pharmacies • Contracts with switch companies for claims delivery
Our Services 1. Electronic claims processing Gate-keeping & eligibility management • Utilisation management services • Clinical management services • Pricing management • Reference pricing • Formulary management • Benefit management services • 2. ChroniLine authorisations 3. Client support 4. Benefit design and consulting
Our Services Electronic Claims Processing
Centralised management Clinical Clinic/Doctor Pharmacy Patient Hospital TTO Information Claims Claims Claims Claims Central Patient Medicine Record (History) at Active Ingredient Level Integrated Utilisation Management & Pharmaceutical Care
Flexibility We can customize • Patient scheme rules for a SINGLE: • Medicine • Provider Each category can be • Prescriber expanded to accommodate specific • Pricing structure requirements such as capitation, formularies and management of virtual networks (on either a positive or negative basis) - NOT a “one size fits all” approach
Gate-keeping and eligibility management Examples: Claim field format checks Provider validation checks Member validation checks Verify dependant code Waiting period check Duplicate check
Utilisation management services Refill limits e.g. 12 fills per year Drug to age range limitations for chronic medication e.g. Ritalin™ and generics will pay for patients 16 years and younger Fill limitations per period Drug to gender limitations e.g. 1 fill per 26 days e.g. HRT females Product quantity limits Invalid prescriber speciality e.g. 200 analgaesics/365 days e.g. Diane™ – Dermatologist Products requiring pre-auth Broad category exclusions e.g. Revelex™ e.g. soaps/shampoos excluded Patient specific exclusions Specific products excluded e.g. for pre-existing conditions and e.g. Urinary antiseptics general waiting periods Pre-existing conditions Waiting periods Patient specific as advised by scheme Patient specific as advised by scheme Utilisation is checked against patient history at active ingredient level
Clinical Management Services Ingredient duplication Drug to age interaction e.g. Stopayne™/ Stilpane ™ e.g. Ciprobay™ under 18 years Maximum daily dose exceeded Drug to gender interaction e.g. Proscar ™ Therapeutic duplication Drug to disease interaction e.g. Zantac™/Tagamet™ e.g. Inderal ™ Asthma Drug to drug interaction Drug to inferred health state e.g. Sporanox™/Fendin™ Drug to allergy – In development All edits are flexible and can be set as reject, informational or report
Pricing Management • Continuous price file maintenance • Various dispensing fee models accommodated • Front-end integration with all pharmacy software packages • Real time price and co-payment messaging on pharmacy desktop • Apply per provider grouping or DSP
Reference pricing Various reference prices are available: • Generic reference pricing MRP - generically similar products • MMAP - generically equivalent products • • Therapeutic reference pricing FRP - formulary based for Chronic • medicines FRP+ - 20% less strict than FRP • This is a financial rule not a clinical decision
Formulary Management • Four different formulary levels are available to allow schemes differentiation between options • Developed and currently maintains Mediscor formularies for the management of CDL PMB and non-CDL conditions • Support provided to clients who maintain their own formularies • Appropriateness of all formularies implemented by Mediscor are reviewed by the Pharmaceutical and Therapeutics (P&T) Committee • Product and disease based look – up facility , per option, available on web page (NEW)
Benefit Management Services • Mediscor uses a single claiming code for a scheme. This ensures that benefit allocation is performed based on scheme rules and pre- authorisations and not by the provider • Accommodates a financial vehicle • Single claim can be paid from two benefits • Benefit validation can be done: In real time through a real-time • switch-out to the scheme Against available reported benefits • supplied on the daily cardholder file
Example prescription Product Paid status Benefit indicator Decision Ventolin (Asthma) P L=PMB Auto Lists Fosamax P M=Chronic Pre-authorisation (Osteoporosis) Panado P F=Savings Benefit rules (Analgesic) Benefit rules Amoxil (Antibiotic) P T=Acute Inteflora Benefit rules R (Supplement) Providers are provided with a clear free-text message on all rejections.
Our Services ChroniLine Authorisations
• Three options available: • Client performs authorisations in-house • Client performs authorisation using ChroniLine software • Mediscor performs authorisation • ChroniLine authorisations currently performed for 30 schemes • Enhanced disease-based authorisation facility • According to algorithms and protocols relevant to the member’s option
• Registration of CDL PMB conditions (complies with Council algorithms) • Authorisation for non-CDL medicines • Pharmacists review, discuss and recommend alternative therapies for non-formulary products • Fully integrated with claiming system • More than 2 million applications have been processed • Future development – ability to carry treatment plans
ChroniLine - Awards 2002: Chronic Medication Management – Gold Award 2003: Chronic Medication Management – Diamond Award 2004: Medicine Utilization Management – Diamond Award Technology Services & Electronic Medicine Management – Diamond Award 2005: Technology Services & Electronic Medicine Management – Diamond Award 2006: Technology Services & Electronic Medicine Management – Gold Award Chronic Medication Management – Gold Award 2008: Chronic Medication Management - Diamond Arrow Award 2009: Technology Services & Electronic Medicine Management – Golden Arrow Award Chronic Medication Management – Diamond Arrow Award
Our Services Client Support
• Call Centre - serves 1 call per 200 claims (provider satisfaction). Calls served are from: Providers • Medical scheme members • Medical scheme’s personnel • • Dedicated client support staff • Claims audit function – verify original Rx to electronic claim • Provider communication by real-time message, web, e-mail, fax, provider-and switch organisations • Member communication – by letter, e-mail or our new SMS facility
Our Services Benefit Design and Consulting
Professional staff comprise: 4 Business development managers (50 yrs experience) • 8 Plan design pharmacists (70 yrs experience) • 3 Benefit design managers (20 yrs experience) • They assist clients with the following: General advice as required • Benefit design and formulary management • Input with regard to managing medicine expenditure • What-if studies • Assist in the interpretation of reports •
Unique Capabilities 1. Information services 2. Business continuity 3. System capabilities 4. Compliant pricing network 5. Measured performance 6. Guarantees
Unique Capabilities Information Services
Mediscor Analyzer An interactive reporting facility that enables clients to: • View their results on-line “Drill down” – this facility makes it easy to view e.g. • medicine expenditure results, industry comparison and profiling Relevant – updated within 10 days • Exports to Excel and other formats • Clients can generate and store own reports • Ability to report per employer •
Benchmarking tool Measure a scheme’s performance against the Mediscor universe, on a like-for-like basis. The tool will also: Allow the universe results to be “ normalised ” Age • Gender • Richness of benefit, per option • Disease profile •
Information and reporting Ad hoc reports Provided on request • REF reporting Provide REF data extracts • (where ChroniLine ™ service is performed) Mediscor Medicines Review (MMR) Reliable annual industry • reference used by private and public healthcare
Unique Capabilities Business Continuity
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