Page 92 - MEDICAL AND HEALTH INSURANCE

MEDICAL AND HEALTH INSURANCE

Fee schedule

This is a comprehensive list of all the fees for specific services, usually applied as the

maximum limit at which the payer has to pay. While this may limit the patient's

maximum exposure at any one time on the specific service, the fee schedule is subject

to review annually, adjusted for medical inflation. It also does not address
underutilization or overutilization on the part of the provider.

Administration

Managed-care Organizations incorporate the financing and delivery of the healthcare
system and must have good management information systems to integrate all their

functions on the overall administration of the company.

The general basic administration functions that the Managed-care Organizations have

to cater to are:

a) 24 -Hour Helpline Service

This will provide accessibility to members to seek advice or assistance for admission. It
also allows the managed-care organizations to co-ordinate the admission more

effectively and in a timely manner with the patient.

b) Data management system for integration with providers' and physicians'

networks

This facilitates online electronic data interchange with the providers and physicians,

whereby claims utilization data is sent directly to the managed-care organizations

computerized system to be processed. This means that whatever is input by the

physician would be immediately updated on the managed-care organizations
computerized system. Real time utilization is achieved and can be intervened, should

the need arise.

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