Medical schemes are continuously focussed on attracting low-risk members, and are actively engaging in risk-management to help drive down healthcare costs and contribution increases. Prescribed Minimum Benefits (PMBs) also play a key part in the costs faced by medical schemes throughout the country. An important part of medical schemes’ strategy to deal with risk is the implementation of managed healthcare interventions to help with the management of chronic and other conditions.

Managed healthcare, in essence, consists of pre-authorisation (approval for hospital admissions and treatment), case and chronic condition management programmes and contracting of designated service provider networks to help contain the costs and also balance the decision making of service providers with cost considerations to make sure the patient experiences the most effective health outcome within reasonable cost.

You, the broker, play an important part in advising clients on suitable medical scheme options. You also probably assist members with claims enquiries and resolutions. During the past decade, members have become increasingly dependent on their broker to resolve claims that were not fully paid by their medical schemes, often as a result of a lack of understanding of the scheme’s managed care policies. Having a clear understanding of the managed healthcare protocols and policies of a medical scheme can play a significant part in helping you to be able to explain these principles to the member before they join the scheme, which in turn will have a significant impact on the number of claims queries you deal with. 

Medical schemes generally negotiate preferential rates for the use of a doctor or hospital network, which is valuable as they then pay lower rates for medical services. However, these contracted service providers may potentially only offer certain services (such as consultations, but not injections). As a result, the member may be faced with having to pay the shortfall of the claim. This creates a major expectation gap between the service expected by the member and the service offered by the medical scheme through the network provider.  It is essential that members are informed to make sure what treatment is covered by the provider before going ahead and to contact the scheme should they be unsure of where to obtain the treatment and services they need.

Understanding the use of provider networks and their significant role in containing costs for the scheme and avoiding co-payments for the member will also help your clients to make proactive decisions regarding their choice of healthcare provider and decrease the number of queries you are approached with, freeing up more time for you to grow your book and sell more products. .