Managed Care Service Level

 

GetMed is a Managed Care Organisation that conducts its services in full compliance with International medical risk

management standards and the principles of sound corporate governance.

 

GetMed provides clinical and financial risk assessment and management to facilitate appropriate and cost-effective

access to the relevant health services by members of a Fund, in accordance with the Fund rules.

 

GetMed renders its services by way of rules-based and clinical management-based programmes, which utilise

documented clinical review criteria that are based upon internationally accepted evidence-based medicine.  

GetMed undertakes to:

 

1. Ensure the confidentiality of all clinical and member information.
2. Employ suitably qualified health care professionals to administer the managed health care programmes and oversee funding decisions, and that the appropriateness of such decisions is evaluated periodically by their clinical peers.  
3. Ensure that treatment is rendered to all members for the Defined Minimum Benefits.  
4. Have in place appropriate mechanisms to ensure the consistent application of clinical review criteria and compatible decisions.  
5. Produce a list of certain conditions for which cover is limited on the basis of evidence-based medicine, cost effectiveness and affordability.  
6. Ensure that all protocols and formularies used in the programmes are based on evidence-based medicine; are evaluated periodically to ensure relevance for funding decisions; consider both cost-effectiveness and affordability; and ensure that provision is made for appropriate exceptions where a protocol and/or formulary has been ineffective or causes or would cause harm to a beneficiary, without penalty to that beneficiary.  
7. Provide access to protocols, formularies and exclusion lists to health care providers, beneficiaries and members of the public, upon request.
8. To use systems and procedures for the early detection and mitigation of irregularities and illegal acts by employees, members and providers.  
9. To provide procedures for complaints or appeals that will in no way impact upon the entitlement of a beneficiary to complain to, or lodge a dispute with the Fund.  
10. To provide access to the Fund to any treatment record held by GetMed and other information pertaining to the diagnosis, treatment and health status of any beneficiary, but such information may not be disclosed to any other person without the express consent of the beneficiary.  
11. To implement policies to employ sufficient and suitably qualified and trained staff, to implement infrastructure information technology and systems to provide the services and to effect its contractual obligations to the Fund.  
12. To use comprehensive off-site data storage, backup and disaster recovery process in compliance with accepted industry norms and standards.  
13. To demonstrate the reporting ability on aspects of service delivery, including service centre, call centres and the recording of pre-authorisations.
14.  To be bound by an agreement that will provide that all the Fund data remains the property of the Fund and copyright vests in the Fund. In addition to existing security measures, GetMed will take such steps as may be required to protect the confidential nature, integrity and assignment of data as far as it relates to the business of the Fund. The data shall be kept and disclosed as per industry norms and standards and as may be required from time to time.
15. To be willing and able to constructively engage and participate with all other service providers that are contracted by the Fund.
16. To undertake that the information will be provided in the required format to the Fund IT provider.
17. To be bound by a managed care agreement to fulfil all functions at least at the level of the industry standard.

 

The scope of work that will be provided by GetMed in terms of its managed care agreement is presented

below and includes:  

• Medicine management  
• Manage Fund members’ utilization of the medicine benefit as defined in the rules of the scheme and the associated cost thereof  
• Pre-authorise access to the chronic medicine benefit  
• Perform a drug utilisation review to ensure appropriate access to and utilisation of the medicine benefit by members of the scheme  
• Apply protocols and formularies to ensure that appropriate and cost-effective drugs are prescribed to members  
• Communicate with the prescribing service provider where indicated  
• Provide medical advisory services  
• Ensure that the members of the scheme have access to the treatment of the Defined Minimum Benefits and the Chronic Disease List in a cost-effective and appropriate manner  
• Provide monthly and quarterly reporting on cost and utilisation profiles, including
• concurrent and retrospective reviews of member and provider utilisation.  

 

• Disease management  
• Provide comprehensive case management to members affected with asthma, diabetes, organ failure, organ transplantation, psychiatric disorders, cardiovascular disease and cancer.  
• The disease management for the conditions listed in (i) must include member education; the promotion of wellness; the pre-authorisation of access to medicine and hospital benefits; and the rational and appropriate management of all costs incurred by the affected members.  
• All members wishing to access treatment and care for the conditions listed in (i) must first be registered on the disease management programme. GetMed will, therefore, provide members with a registration service to which they apply prior to accessing the relevant benefits.  
• Apply protocols and formularies to ensure that appropriate treatment is rendered to members in a cost-effective manner  
• Communicate with the treating service provider where indicated  
• Provide medical advisory services  
• Provide monthly and quarterly reporting on cost and utilisation profiles, including concurrent and retrospective reviews of member and provider utilisation.  

 

• Dentistry and optometry management  
• Apply a rules-based programme to ensure that cost-effective and appropriate care is rendered to members in respect of the optometry and dentistry benefits as contained in the schemes rules  
• The management of this programme must be based on standard operating procedures, protocols and formularies to ensure that appropriate treatment is rendered to members in a cost-effective manner  
• Communicate with the treating service provider where indicated  
• Provide medical advisory services  
• Provide monthly and quarterly reporting on cost and utilisation profiles, including concurrent and retrospective reviews of member and provider utilisation.  

 

• Provider management  
• Perform retrospective reviews of the utilisation and costs associated with the providers (general practitioners, dentists and specialists) who have rendered treatment to members of the Fund.  
• Identify appropriate statistical norms/averages of care  
• Identify those providers that have displayed abnormal behavioural trends and communicate these findings to the provider  
• Recommend corrective measures to the Principal Officer for approval prior to implementation thereof and implement these measures once approved by the Board of Trustees  
• Provide monthly and quarterly reporting on cost and utilisation profiles, including concurrent and retrospective reviews of member and provider utilization.