Mediscor Workshop Presentation 11 August 2010 Content 1. Profile - - PowerPoint PPT Presentation

Mediscor

Workshop Presentation

11 August 2010

Presented by:

Christo Rademan - Managing Director

• 1. Profile overview
• 2. Our services
• 3. Unique capabilities
• 4. Conclusions

Content

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

• 1st 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

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

Our Services

Electronic Claims Processing

Integrated Utilisation Management & Pharmaceutical Care

Pharmacy Claims Patient Claims Clinic/Doctor Claims Hospital TTO Claims

Central Patient Medicine Record (History) at Active Ingredient Level

Clinical Information

Centralised management

We can customize scheme rules for a SINGLE:

Flexibility

• Patient
• Medicine
• Provider
• Prescriber
• Pricing structure

Each category can be expanded to accommodate specific requirements such as capitation, formularies and management of virtual networks (on either a positive or negative basis)

• NOT a “one size fits

all” approach

 Claim field format checks  Provider validation checks  Member validation checks  Verify dependant code  Waiting period check  Duplicate check

Gate-keeping and eligibility management

Examples:

Refill limits e.g. 12 fills per year for chronic medication Drug to age range limitations e.g. Ritalin™ and generics will pay for patients 16 years and younger Fill limitations per period e.g. 1 fill per 26 days Drug to gender limitations e.g. HRT females Product quantity limits e.g. 200 analgaesics/365 days Invalid prescriber speciality e.g. Diane™ – Dermatologist Products requiring pre-auth e.g. Revelex™ Broad category exclusions e.g. soaps/shampoos excluded Patient specific exclusions e.g. for pre-existing conditions and general waiting periods Specific products excluded e.g. Urinary antiseptics Pre-existing conditions Patient specific as advised by scheme Waiting periods Patient specific as advised by scheme

Utilisation is checked against patient history at active ingredient level

Utilisation management services

Ingredient duplication e.g. Stopayne™/Stilpane™ Drug to age interaction e.g. Ciprobay™ under 18 years Maximum daily dose exceeded Drug to gender interaction e.g. Proscar™ Therapeutic duplication e.g. Zantac™/Tagamet™ Drug to disease interaction e.g. Inderal™ Asthma Drug to drug interaction e.g. Sporanox™/Fendin™ Drug to inferred health state Drug to allergy – In development

All edits are flexible and can be set as reject, informational or report

Clinical Management Services

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

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

Reference pricing

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
• ption, available on web page (NEW)

• 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

Benefit Management Services

Product Paid status Benefit indicator Decision

Ventolin (Asthma) P L=PMB Auto Lists Fosamax (Osteoporosis) P M=Chronic Pre-authorisation Panado (Analgesic) P F=Savings Benefit rules Amoxil (Antibiotic) P T=Acute Benefit rules Inteflora (Supplement) R Benefit rules Providers are provided with a clear free-text message on all rejections.

Example prescription

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

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

ChroniLine - Awards

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

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

Mediscor Analyzer

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

Benchmarking tool

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

Information and reporting

Unique Capabilities

Business Continuity

Providers SWITCH Mediscor PBM SWITCH Mediscor PBM

Scheme / Administrator

Supported by:

• Back-ups stored off site
• On site generator and UPS

Unique Capabilities

System Capabilities

Mediscor uses two types of software: Core PBM software

• Developed by SXC, a Toronto listed company
• The software currently manages more than 120 million

lives in other countries

• Positive result - we have access to all system

developments/enhancements that other users initiate

Local Customised software

• Facilitates the customisation of client/legislated rule

changes

• Ensures that Mediscor is able to offer clients fast and

flexible solutions

Leader in PBM software

System Performance

• The Medi-Span database is fully integrated with our

SXC software

• One of the top two product databases in the world
• Medi-Span employs 160 staff in 16 countries
• Carries package insert of every product in code

form

• Intelligent GPI code (mapped to NAPPI) at active

ingredient level

• Facilitates:
• Pharmaceutical utilisation management
• Clinical rules
• Comprehensive clinical evaluation
• Good pharmaceutical care

Medi-Span intelligent product database

Mediscor has a proven integration track record:

• Real-time switch out to administration platform
• 18 Administration platforms e.g. Nexus, MIP, NHA
• Various switch companies e.g. Switch,

HealthBridge, QEDI

• Managed care providers e.g. MSO, PrimeCure, Aid

for AIDS, Optipharm

• MSO data exchange – hospitalisation and disease

information

Integration

Unique Capabilities

Compliant pricing network

• Consists of over 500 individual pharmacies,

pharmacy groupings and courier/postal pharmacies

• All have undertaken to charge a maximum of

SEP + the “regulated” R26/26% fees, without any additional fees

• Available to all medical scheme clients

Compliant Pricing Pharmacy Network

Unique Capabilities

Measured performance

• Mediscor measures and reports the results of
• ur interventions on a monthly basis
• Mediscor provides a savings guarantee ensuring

that our fees are not more than the savings delivered to our clients

• Our role in non-healthcare costs can confidently be

justified to the Council for Medical Schemes

Value based performance

Savings measured and reported

Service Category Value 2009 Value 2008 Claims Processing:

Utilisation management 378,505,426 267,806,333 Clinical management 65,474,715 55,577,311 Pricing management 126,327,487 111,082,707 Reference price 113,646,496 79,868,485

ChroniLine™

13,222,407 8,595,912

TOTAL 697,176,531 522,930,748 Multiple of fees paid 8.7x 6.9x

Unique Capabilities

Guarantees

• Mediscor contractually guarantees the accuracy
• f claims processing
• Assurance that if an event does occur, Mediscor will

reimburse the scheme’s damage

• For this purpose Mediscor carries insurance
• Insurable and uninsurable events are covered up to

a ceiling amount

Guaranteed accuracy of claims processing

• Mediscor maintains a comprehensive set of scheme

rule test scenarios that are run daily

• The results of the QA-scenarios (currently 4000)

are evaluated electronically against set outcomes

• The financial component of all claims are daily re-

checked on our Pythagoras system

• Outliers are referred to a qualified plan design

pharmacist for investigation

• This ensures that rules are applied correctly and

consistently, every day

Quality Assurance (QA)

Conclusions

Our flexible, open business culture is focused on building successful clients

• Mediscor is a centre of excellence
• Mediscor has expert staff, systems and knowledge
• Mediscor has an intimate understanding of our

client’s objectives, rules, membership profile and treatment protocols

• Mediscor provides:
• Comfort
• Reliable information
• Guaranteed performance
• Savings on your medicine expenditure