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METROPOLITAN HEALTH PROVIDER MANAGEMENT VALUE-ADDED OFFERING AND SERVICES –

FOCUSSING ON PRIMARY CARE

The Provider Management Department has been mandated to manage all issues relating to healthcare providers

on behalf of Metropolitan Health. Healthcare providers are defined in the broadest sense and include all

organisations and individuals that provide healthcare products and a service to members of Metropolitan Health

client schemes, either directly or indirectly.

The Provider Management Department has both an internal and external focus. In terms of its internal focus, it is

tasked with the development, implementation and management of provider networks for client schemes

administered by Metropolitan Health. In the primary care space, such provider networks incorporate the

following services: general practitioner, pharmacy, dental, optometry, emergency medical services (EMS),

pathology and radiology.

As the link between providers and the scheme business units, Provider Management also functions as a conduit

for channelling provider issues to Metropolitan Health clients and vice versa. This unique perspective allows the

Department to provide valuable input into managed care solutions, enriched by a view of both the provider and

client requirements. The external focus of the business is supported through attendance at business, professional

and government forums, and interaction with relevant industry stakeholders.

The evolution of healthcare legislation along with the need to provide affordable, high-quality and accessible

healthcare to a broader section of the South African population has resulted in the inclusion of a range of

provider networks in medical schemes’ benefit structures. It is envisaged that this focus on provider relations will

increase and Metropolitan Health Risk Management has developed significant capacity within the Provider

Management Department to ensure that our client medical schemes have access to an increasing range of

provider networks. This fosters the growth of partnerships which support the delivery of cost-effective and

quality healthcare.

The management of all our provider networks is aligned to our objective of providing excellent access to quality

healthcare for scheme members. To this end, network provider locations are aligned to scheme member

demographics. Growth in the geographic footprint of our networks is promoted through an approach that favours

the inclusion of providers already servicing members (natural usage) and those that wish to be part of the

network (willing providers). This approach has resulted in the development of large national networks (especially

in the primary care arena) with excellent coverage of members. Partnerships with professional provider

organisations have supported the growth of such networks and participation by members.

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Network management The overarching objective of the Metropolitan Health Provider Management Department is to ensure that

members have adequate access to an integrated, national network of cost-effective and quality providers,

inclusive of hospitals, specialists, general practitioners, pharmacists, dentists and optometrists for services both

in- and out-of-hospital. The main focus areas are:

• Primary Care networks

• Specialists networks

• Hospital networks

• Procurement of medical equipment and services

• Procurement of pharmaceutical lifestyle programmes

• Pharmaceutical benefit and network management

These focus areas allow for the optimisation of Metropolitan Health Risk Management's operational capabilities

to provide a consolidated network approach to providers and schemes.

Internal focus External focus

• Develop, implement and manage provider

products for Metropolitan Health

• Represent provider issues in front of Metropolitan

Health clients

• Representing Metropolitan Health and client issues

in front of the providers

• Represent Metropolitan Health in professional,

business and governmental forums

Provider Management in the primary care space

Provider Management in the primary care space involves providers who deliver the following services: general

practitioner services, pharmacy, dental care, emergency medical services (EMS), optometry and to a limited

extent, pathology and radiological services.

Figure 1: Primary care focus areas

The service provided in the primary care space may be broadly categorised into two core areas and two support

areas. The two core areas focus on:

• Provider engagement and networks

• Healthcare negotiations and business modelling

The support areas provide project management and operational support for the primary care areas of work.

These are broadly classified as:

• Provider operations

• Project and innovation

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Provider engagement and networks

This essentially entails the development, design and management of networks of primary care providers to

deliver services to scheme beneficiaries. Relationship management is central to Provider Management; so much

time and effort is expended to develop constructive and meaningful relationships with providers to positively

influence cost-effective and quality healthcare. In the GP arena this is reflected in a close working relationship and

regular meetings with the Independent Practitioners’ Associations (IPA) Foundation. Regular engagement with

professional representative bodies is also undertaken.

Quality assurance focuses on evaluating contractual compliance by providers. Network requirements allow for the

evaluation of the clinical practice, operational and financial efficiency of providers in the primary care space

through profiling and peer review mechanisms which are currently implemented for GP networks. This process is

driven by the strong partnership with the IPA Foundation, which takes responsibility for the peer review process.

Profiling tools are currently being developed to evaluate the quality of pharmacy practice. Since data is collected

on a continuous basis on the practice of primary care providers, trend analysis is conducted to evaluate changes

in practice and profiling scores from one quarter to another. This allows for comparisons between the

performance of network with non-network providers. It may also signal risk areas that should be addressed or be

subject to intervention. Alternative reimbursement models are utilised to reward excellent performance in the

provider space.

Healthcare negotiations and business modelling

Negotiations are carried out on an annual basis with service providers to arrive at cost-effective tariffs for services

provided. This is aimed at ensuring the delivery of quality and sustainable healthcare to beneficiaries. Currently

this engagement happens with the GP and pharmacy providers mainly. Assessment and interpretation of data

generated by network practices’ claims profile provide a basis for developing strategy and innovation in managing

the partnership with primary care providers.

Management support services

The operational team, managed by a senior operations manager, works very closely on the delivery of provider

management services and drives communication between the various stakeholders. This is achieved via a call

centre staffed with experienced consultants who respond to queries from providers and beneficiaries. The call

centre staff are also actively engaged in building the various networks, performing administrative duties related

to developing the networks and facilitating communication with providers.

A national team of provider network consultants (PNCs) work in the field, calling upon network doctors on a

regular basis to keep them abreast of new developments. They facilitate communication with providers and

address issues raised by providers.

Core service areas

Provider engagement and networks Healthcare negotiations and business modelling

• Relationships

• Networks

• Quality assurance and compliance design

• Trend analysis

• Negotiations

• Contracting

• Business modelling and analysis

Support service areas

Provider operations Project and innovation

• Call centre operations

• Enrolments and contracting

• Quality assurance

• Provider Network Consultants

• Projects Office and Management

• Implementations

• Innovations

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The strategic values that Provider Management delivers are the following:

• Understanding of the healthcare market from both a provider and funder perspective

• Strong relationships with providers across the market

• Ability to design, implement and manage provider networks

• Expertise in healthcare purchasing and negotiation skills

• Management of advanced reimbursement models

• Strong operational interface, both internally and externally

• Research, implementation and use of electronic business application

• Provider-centric service and query resolution management

• Strong business development capabilities

• Influence and contribute towards healthcare industry developments

The Provider Management Department strives to achieve access to cost-effective healthcare without

compromising quality in health outcomes for its clients. It does this through a strong collaborative approach

involving both provider partners and medical scheme clients. It is therefore perfectly positioned to support the

relationships between providers and funders of healthcare services with the aim of delivering the best value and

quality of care to members of medical schemes.

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DE-MYSTIFYING HOSPITAL AUTHORISATION LOCKS (‘AUTH-LOCK’)

The Hospital Risk Management Department has instituted a new business process aimed at managing the risk

associated with authorisations that go over the initial Length of Stay approved by the business, through the e-

auth or the manual capturing of the authorisation details.

When authorisations are captured based on clinical appropriateness and benefit availability, the authorisation will

be stamped with a pre-determined number of days and a concomitant level of care. These guidelines are

determined through sound clinical governance process.

In the example given below – should the patient still be in hospital on the Monday morning (27/08/2012), the

updated information will need to be communicated to Metropolitan Health Risk Management as soon as possible,

failing which, the auth will lock on the Wednesday (29/08/2012). The provider needs to bear in mind that once

sent to Metropolitan Health Risk Management, there is a one-day turnaround time for updates that do not

require letters of motivation or doctors reports.

Example:

Scheme name Date of admission Date of discharge Guideline

approved

Length of Stay

Diagnosis Auth lock date

Scheme X 23/08/2012 25/08/2012 3 days General

Ward

Pneumonia 29/08/2012

Any further update following the three-day lapse, once the authorisation is locked, will require clinical

intervention to determine the reason behind the time lapse and the need to unlock the authorisation and

perform the update.

Updates sent in by the service providers more than three days following a discharge information update are going

to take longer to resolve, as these will be fully investigated and the claims related to that authorisation

scrutinised. Back-log and inefficient processes in the service provider space will result in delays in getting updates

finalised as the authorisation will be locked.

Some service providers do provide Metropolitan Health Risk Management with final updates. Once these are

actioned by a case manager, the authorisation will be manually locked and will not wait the three days to system

lock.

It is in the best interest of ALL service providers to finalise authorisation details and updates timeously.

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For ease of reference, click here to view the service provider escalation matrix for hospital authorisation and

related queries for all medical aid schemes managed by Metropolitan Health Risk Management:

• Afrox Medical Aid Society

• Anglo Medical Scheme

• Bankmed

• BP Medical Aid Society

• Engen Medical Benefit Fund

• Fishmed

• Golden Arrow Employees’ Medical Benefit Fund

• Imperialmed

• MEDiPOS

• Metropolitan Medical Scheme

• Alliance Midmed

• Momentum Health

• Moto Health Care

• Nampak Health

• Netcare Medical Scheme

• PG Group Medical Scheme

• POLMED

• South African Breweries (SAB) Medical Scheme

• SAMWUMED

• Sappi Medical Aid Scheme

• TopMed

• Transmed

• Wooltru Healthcare Fund

ELECTRONIC ONLINE HIV COUNSELLING AND TESTING (HCT) PROCESS 2012

As you may be aware, South Africa has a high prevalence of HIV, with a low percentage of citizens who know their

status.

In April 2010, the Minister of Health launched the national HIV Counselling and Testing (HCT) campaign with a

message encouraging all sectors to collaborate and support this initiative.

In light of this, several medical schemes in partnership with Metropolitan Health Risk Management have taken up

the call and are offering a solution aimed at improving accessibility to HIV testing, thereby empowering you to

take the first step towards offering FREE testing for all your patients.

NOTE: These screening tests should be claimed for under ICD-10 code Z11.4

The Metropolitan Health Provider Management Department in partnership with the HIV YourLife Programme has

converted the HCT form to a fully electronic online process. The new HCT form is a single-page electronic

questionnaire which automatically generates a claim once submitted electronically.

You may access the HCT consent form and HCT questionnaire via Service Provider Online on the participating

schemes’ websites:

• BP Medical Aid Society (www.bpmas.co.za)

• Engen Medical Benefit Fund (www.engenmed.co.za)

• Wooltru Healthcare Fund (www.wooltruhealthcarefund.co.za)

The HCT questionnaires must be submitted electronically only; manual forms will not be accepted for processing.

Please click here to view the detailed training manual.

For assistance or further information in this regard, please contact the Provider Management Department on the

following details:

Tel: 021 480 4530

Fax: 021 480 2733

E-mail: networks@metropolitanhrm.co.za

Website: www.metropolitanhrm.co.za

Contact the HIV YourLife Programme on 0800 117 868.