The goals of Mediscor PBM are to:
- Manage the medicine benefits of our contracted medical schemes cost-effectively;
- Provide a leading, flexible and reliable medicine management solution;
- Supply appropriate guarantees and measurements of performance;
- Timeously provide reliable scheme and industry benchmark information.
Summary of Services
Mediscor is a specialist organisation focusing exclusively on delivering a comprehensive medicine management solution. This strategic position is clear and supplementary to that of an administrator.
1. Electronic claims processing
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We offer reliable and high performance real-time claims processing, performed at item level on all benefit options, in the following categories:
Data integrity validation – e.g. field completeness.
Eligibility management – e.g. patient, provider and prescriber checks against BHF.
Utilisation management – e.g. product exclusions, quantity and refill limits.
Clinical management – e.g. drug interactions and dose checks.
Formulary compliance management – e.g. preferred product selection.
Provider management – e.g. pharmacy contracts, prescribers, networks.
Price management – e.g. product price, pricing, dispensing fees and co-payments.
Reference price management – e.g. generic, MRP or therapeutic.
Benefit validation – e.g. financial limits.
A customised set of rules is implemented for every client. The Mediscor system's inherent flexibility allows customisation of funding rules for a single member, product, provider, benefit category or condition.
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2. ChroniLine services
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Our authorisation service is known as Mediscor ChroniLine®. Patient access to specific medication is initiated by a registration process performed either telephonically, by fax or e-mail by the prescriber, pharmacist or member. Chronic medicines are managed according to client's choice ranging from system-driven automated medicine lists, down to comprehensive item level authorisations.
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3. Data Analysis and Reporting
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Mediscor delivers a comprehensive reporting and data analysis service through our interactive reporting facility, the Mediscor Analyzer™. This enables clients to view their results on-line and generate their own reports. Mediscor also developed a sophisticated analytical model, named Patient Experience Monitor, which measures a patient's financial experience at point of sale.
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4. Consulting and Advisory Service
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Our professional medical and pharmaceutical staff are available should you require advice, information or assistance in benefit design, formulary management or input in regard to reducing / managing medicine expenditure. The interpretation of reports and results are also available on request.
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5. Client Support Services
We provide the following:
- 116 staff in total with 40 health professionals.
- Call centre for members and providers – available 7 days a week.
- Dedicated client support teams.
- Dedicated provider relations team.
- Ad-hoc patient advance supply approvals and appeals process management.
Provider communication by real-time messages, web, e-mail, fax and through MediSwitch and Healthbridge. NEW on-line lookup facilities (web based) for brokers to search formulary products.Provider communication by real-time messages, web, e-mail, fax and through MediSwitch and Healthbridge. NEW SMS patient communication facility to alert patients at the time of dispensing that for e.g. a generic alternative is available. Please note that this is a separately quoted service not included in the service fee.
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6. Supplementary Services
7. Quality Management Programme
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We apply stringent automated quality control measures to ensure that all rules and every claim is quality checked on a daily basis. These measures includes rules auditing, processed claims auditing (verified by an independent system), authorisation auditing and paper claims audit. This is why we can contractually guarantee both savings and the accuracy of our claims processing. |
8. Doctor Claims
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Within the South African industry, Mediscor receives claims from all switches, e.g. Healthbridge, Mediswitch and all doctor bureaus. Rules in terms of registered scope of practice regulated for each provider group are applied. |
9. Paper Claims
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Mediscor has developed several mechanisms through which we can receive paper claim information that is submitted directly to our clients. Receiving paper information that is submitted through the Mediscor PBM system ensures that we carry a comprehensive patient history and facilitates accurate reporting and patient profiling. |
Last Update: 28 January 2015
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