“The systems medical scheme administrators use should put members first at all times, and cannot be at the expense of healthcare practitioners who have already provided their services,” asserts chief executive officer of medical scheme administrator and managed care provider Agility Health, Patrick Masobe. 

“Healthcare professionals’ rare skills are invaluable. As an industry we need to ensure that the claims management systems we use are geared towards supporting doctors and other health practitioners because they are absolutely vital to ensuring better health outcomes for members,” he notes.

“The notion of clawing back funds that have already been paid out to providers is antiquated and anachronistic – it is simply inexcusable given the technological tools and skills that are on offer nowadays,” adds Wilma Liebenberg, chief executive officer of Knowledge Objects (KO), which specialises in the development of next generation administration and risk management systems in the health and financial services industry through the deployment of artificial intelligence and rule-based technology. 

“Artificial intelligence technology has allowed us to prevent fraud, waste and abuse for the past 11 years, and concerns of blatant FWA therefore belong in a museum with the dinosaurs,” she says. 

“It is most disconcerting that the industry norm still involves trawling and auditing of outliers performed retrospectively, and in many instances even manually, which allows for FWA to deplete scheme resources before detection. Not only is this a laborious process, but it is also grossly inefficient and prejudicial. Needless to say, it has enormous repercussions for healthcare providers when medical schemes later try to claw back claims they have already paid.” 

Liebenberg explains that in contrast, intelligent systems, such as those developed by KO, focus on proactive claims management, with 100% of the analysis conducted at this level. “Retrospective algorithmic rules are used to continuously analyse big data to detect trends and enhance the real-time analysis, however there is no profiling of either members or providers for future punitive action.

“No wonder it allows for unique and advanced methodologies, as the KO system is the only end-to-end administration system developed in South Africa during the past decade, hence not just another legacy system that is being bent to look like something new.” 

Masobe adds: “In this environment of proactive risk management, profiling is done to ensure future best practice models, as opposed to historical ‘wrongdoing’. FWA is therefore pre-empted and there is never any need to claw back funds from providers, let alone to profile healthcare providers.”  

 

KO provides its source code owned and developed software to clients globally, including Agility Health in South Africa. Through a myriad of rules, algorithms and protocols embedded in the software, as well as machine learning processes, clinically inappropriate claims are flagged pre-emptively, whilst simultaneously deployed to detect risk patterns and therefore support an individual with a predictable threat to his or her health. This is a win-win situation which adds value for medical schemes, client companies and their members.

“Systems should focus on patient outcomes while verifying, for example, that the provider is, firstly, the appropriate health professional to be providing the treatment, and whether the appropriate treatment was conducted for the ailment in terms of best practice. All claims are processed on their own merit and the historic claim patterns are not utilised to the provider’s disadvantage,” she says. 

“The purpose is to confirm that quality, appropriate care is at all times being provided, and to support healthcare practitioners to ensure better clinical outcomes for their patients.” 

Agility Health has been making use of the KO software solution for more than eleven years. “Our whole approach is geared towards ensuring the members’ health comes first, and this is effectively supported by KO’s software. The integrated software of KO allowed Agility Health to develop its duly integrated and patented Patient Driven Care™ [PDC] programme, whereby members and patients are cared for across all diseases and ailments through an integrated health profile and not on the basis of separate diseases for the same patient,” Masobe says.

“If the systems detect through the big data analysis that a member may be at potential risk for a health event, such as a stroke or heart attack, we reach out to them with an intensive clinical support programme to help improve their wellness and, very often, prevent adverse health events,” Masobe continues.

This patient-centred approach includes marrying the claims history of patients with the tracking of disease-specific markers, such as blood glucose readings for members with diabetes, blood pressure for those with cardiovascular disease, peak flow for asthmatics, cholesterol levels for those with hyperlipidaemia, etcetera. 

Nursing professionals then act as Personal Health Coordinators, supporting adherence to prescribed treatment through automated alerts. The alerts are triggered through a predictive modelling module built into the software, which in turn has built-in algorithms whereby the appropriate care is guided to the patient. This could include home visits, unlocking additional consultations and best practice guidelines; all in consultation with the treating practitioner and thereby enhancing the service to the patient, whilst working in partnership with the patient’s practitioner. 

In a comparison of the same cohort of members across two consecutive years, it was found that after the PDC intervention these members had 24% fewer hospital admissions, indicating fewer serious health events. 

“Prevention is always better than cure, and prioritising members’ health is also more cost-effective for the medical scheme. The partnership with providers is essential in the execution of proper risk management principles, which is executed through pre-emptive claims management and certainty created about funded benefits and best practice,” Masobe says.

“The prevention of retrospective clawback processes ensure that providers are trained towards these best practice guidelines and practice accordingly in instances where Agility Health is the administrator and risk manager. A case study undertaken by Agility Health illustrated that even where additional benefits are allocated to members to proactively improve their health and wellbeing, overall there was still significant savings of 3,1% on cost of hospital admissions and 11,8% on medicines expenditure,” he says.

Virtually instantaneous claims review decision-making software has a further advantage for members, as this proactive risk management approach assists to maintain the need for exorbitant annual increases on medical schemes’ contributions.  

“Our experience has shown that the use of this advanced real-time rules engine, together with engagement with healthcare service providers and members, enhances the medical care provided. Empowered with practical health advice and access to the most relevant healthcare resources, medical scheme members are supported to live healthier lives while healthcare providers are equipped with valuable clinical information to optimise outcomes for their patients,” Masobe concluded.