Breaking new ground improves outcomes, but also ruffles feathers
Patrick Masobe, Chief Executive Officer of Agility Health.
Protecting medical scheme members requires powerful, intelligent systems.
Medical schemes have a fiduciary responsibility to protect and efficiently manage the funds of their members, and the intelligent systems employed by the scheme’s administrator have a significant role in safeguarding these resources.
“There are a multitude of intersecting factors that can erode the resources medical schemes have available to cover legitimate claims for their members. In this highly complex environment, it is essential to take into account the full spectrum of clinical, actuarial and other related factors in a truly integrated manner,” says Patrick Masobe, Chief Executive Officer of Agility Health.
Agility Health’s approach to managed care and administration of medical schemes is backed by an embedded intelligence rules engine that has been developed to apply a complex set of protocols and guidelines established by a panel of medical professionals and experts from various fields.
“The market is accustomed to disjointed systems and point solutions that fail to take into account the full range of factors that claims should be checked against to establish their validity.
“In order to protect the majority of the scheme members and ensure their funds remain available for legitimate claims, the real-time technological solutions we use are backed by strong provider network agreements and clinical protocols that are enforced to protect against abuse and misuse of benefits through active management of the demand and supply side of the equilibrium,” Masobe explains.
“Our systems are, for example, programmed to be highly adept at detecting over-servicing that is not medically necessary, thereby reining in wastage without compromising the care members are entitled to. This becomes particularly important in a Prescribed Minimum Benefits [PMBs] environment.
“By law, these conditions must be covered by medical schemes in full, a notion that has been a source of great concern for the sustainability of the industry since the National Health Reference Price List was scrapped several years ago. Claims related to Prescribed Minimum Benefits are not, however, a blank cheque and it becomes integrally important that robust systems are in place to instantaneously detect any claims discrepancies.
“The intellectual property we use allows for online, real time verification of claims and claim lines through identifying anomalies in medical scheme claims submissions. As time is of the essence for our medical scheme clients and their members, this process does not reduce the speed at which the millions of claims are assessed,” he observes.
“Irregularities in claims submissions are therefore identified, and the rules engine is able to recognise patterns in claims behaviour, either at healthcare provider or member level.”
This is characteristic of Agility Health’s integrated approach to medical scheme administration. The technology employed by Agility Health for Resolution Health Medical Scheme and Spectramed Medical Scheme automatically flags inappropriate claims and unusual risk patterns while providing comprehensive information required to take action and investigate possible fraud.
“This has helped to ensure that the schemes we administer are able to achieve the elusive balance between keeping member contribution increases to a minimum in a market burdened with high medical inflation, such as rampant growth in hospitalisation costs, while ensuring the future sustainability and viability of the Scheme.
“These interventions have, for example, greatly assisted Resolution Health to substantially and consistently grow its reserves in recent years from single digits to a projected 17% end-2017 while consistently keeping its annual increases in line with, market trends. The turnaround is near unheard of in the market,” Masobe notes.
From a managed care perspective, one of the additional advantages of this system is its ability to achieve a coveted balance between ensuring appropriate benefit provision and enhanced health outcomes without compromising the detection of claims submission anomalies.
“The system places a key focus on achieving improved health outcomes for members while consistently checking claims against clinical rules and established treatment protocols. As a result, we are not only protecting the wellbeing of the medical scheme members, but also the financial health of the scheme.”
Further bolstering the outcomes for medical schemes under Agility Health’s management is its robust fraud-prevention capabilities with the application of this highly sophisticated system outshining the checks applied in much of the rest of the healthcare funding industry.
“This has meant that our exceptional systems have given rise to an increase in queries, as the market is not yet accustomed to such a highly-attuned system. However, the protocols and guidelines embedded in the system have proved their mettle internationally, as we have exported this intellectual property to various countries across four continents,” Masobe elaborates.
Agility Health is particularly vigilant when it comes to over-servicing, the practise of ‘code-farming’ and duplication of claims, which sometimes sparks complaints from certain healthcare practitioners who may be engaging in such behaviours.
It is furthermore true that a great many medical scheme members and other stakeholders, such as healthcare providers, tend to misunderstand why their claims are at times rejected. This is in part due to the highly complex environment of the healthcare industry in general, and the unique protocols and rules enforced by each individual medical scheme.
This often stimulates the submission of queries of a doubtful nature. Any analysis of the most recent Council for Medical Schemes’ Annual Report on the relative number of complaints against schemes should take into account that the number of complaints is not so much a reflection on the Schemes, and their inability to satisfy their obligations to members, as many of the complaints lodged are not upheld by the regulator.
“In fact, when looking at the latest CMS Annual Report, only 36% of total open medical scheme complaints received by the industry regulator were ruled in favour of the complainant. This trend is similarly true for both Schemes administered by Agility Health with a low 20% of total complaints ruled in favour of the complainant during the same period. Not only is this well below the industry average of 36%, but also clearly illustrative of Agility Health’s sophisticated rules engine being very much in line with regulatory parameters,” he adds.
One of the biggest causes for anxiety within the industry is Prescribed Minimum Benefits (PMBs), which are arguably the most complex benefit categories to navigate from both a provider and member perspective. Accordingly, a large portion of complaints received by medical schemes under administration by Agility Health are PMB-related. The incorrect use of ICD10 codes, combined with a widespread lack of understanding, is more often than not at the root of these difficulties.
“We recognise that healthcare service providers are not coding specialists and it is therefore not surprising that they might make errors from time to time. Our system allows for such errors to be queried and corrected, where appropriate, through our custom-designed service interventions.
“A small minority of healthcare providers who attempt to capitalise on medical schemes have taken issue with our efforts to clamp down on unacceptable practices, such as code farming. Some of them appear to be encouraging their patients to submit complaints against the schemes that have processes in place to protect members’ funds. Most of the finalised complaints were, however, deemed invalid by the CMS.”
Masobe notes that it is the responsibility of every player in the industry to assist medical schemes in combatting fraudulent activity. “This is particularly true for members, who are most directly affected by the consequences of fraud. The costs of fraud ultimately drive up the cost of healthcare, and therefore it holds true that fraudulent medical scheme claims negatively affect all consumers,” he concludes.
