Managed care design is key to achieving value

Managing medical scheme funds effectively on behalf of members is a delicate balancing act between offering maximum cover for quality private healthcare and maintaining affordability in light of rising medical costs.

Mark Arnold, principal officer of Resolution Health Medical Scheme explains, “Members rely on us to ensure their funds are being managed prudently and offer the best possible healthcare access for their money. The design of a scheme’s managed care is key to optimising value.

“However, our integrated approach to managed care and risk management principles goes a step further, by empowering our members with an advanced claims management system. It actively checks patients’ treatment and conditions for contraindications and potential health risk through finely attuned clinical protocols.

Where the system identifies problematic claims, a team of clinical professionals reviews the details, engages with the patient and the medical practitioner, then establishes the clinical and procedural validity of the prescribed treatment and claim.

“This system is highly adept at weeding out potentially harmful treatment combinations as well as eliminating wasteful expenditure and abuse of scheme resources. Value is achieved by ensuring claims are legitimate and therefore make the best possible use of members’ funds. An additional layer of protection for members is also achieved by confirming adherence with clinical protocols,” he observes.

“The Resolution Health approach to product enhancement and richness ensures that members enjoy more of the benefits they use the most, ensuring relevant value for money. Moreover, the good health of our members is central to our philosophy as a medical scheme.

The measures incorporated into our approach reflects our commitment to provide true value at every opportunity while ensuring our members have access to the most appropriate care at all times,”