Technology has come a long way in terms of the efficiency in handling healthcare claims since the early 1990s.

Through the development of specific coding systems and ever more advanced rules engines and algorithms, artificial intelligence and human clinical expertise are increasingly coming together to optimise the claims handling process to enhance value for healthcare consumers.

“In the early days, medical scheme claims were predominantly paper claims with very few established coding standards in place,” says Wilma Liebenberg, CEO of Knowledge Objects Healthcare, a company specialising in effective risk management and higher automation solutions within the healthcare funding industry.

“As a result, claims handling involved mountains of paperwork, in which different role players within the healthcare value chain were all using a different language to communicate. This was before the introduction of unambiguous coding systems that we use today to signify different diagnoses, medicines, healthcare services and hospital procedures.”

According to Liebenberg, the lack of a uniform set of industry-accepted codes meant that miscommunication and mistakes could creep into the claims handling process, which was also more open to discretionary payments on potentially invalid claims that were often wasteful.

“Recently the industry has been more outspoken about fraud, waste and abuse in medical scheme claims, but these have always been present. We are now more adept at identifying these problems and through advanced technological solutions working in real-time, such as those developed by Knowledge Objects Healthcare, we are increasingly able to weed out invalid claims.”

By the late-1990s, various codes were introduced to build up a common ‘language’ for the healthcare industry in South Africa. These included adopting a system of universal diagnostic codes introduced by the World Health Organization known as ICD-10 codes, current Procedural Terminology 4th Edition (CPT-4) codes for hospital procedures and the National Pharmaceutical Product Index, commonly known as NAPPI® codes, and National Reference Price (NRPL) List codes and South Medical Association Billing codes (SAMA).

“The advent of these codes meant the quality of data was better and advances in technology made it easier to handle large volumes of information, and as a consequence claims handling systems became more effective.

“However, there is still considerable difficulty at the point of sale, for example doctors’ rooms, because medical schemes independently determine and negotiate tariff pricing with healthcare providers, and disparate rates for different schemes makes pricing complex and administration more labour intensive – particularly when each year’s new negotiated tariffs are implemented,” she adds.

When Prescribed Minimum Benefits (PMBs), a set of conditions that medical schemes are obliged to cover, were introduced they were widely misunderstood and many non-PMB conditions were claimed for as PMBs.

“The tendency of some healthcare providers to exploit the system stimulated a new shift in claims handling processes. Clinical verification was introduced to provide clinical approval and prevent non-PMB claims being padded with invalid PMB codes and pricing. With the proposed changes to South Africa’s medical schemes and healthcare environment, it follows that technology will need to evolve to keep pace with developments,” Liebenberg notes.

“The ever-increasing sophistication of people seeking to defraud or abuse medical schemes means technology must be dynamic to effectively manage risk. We at Knowledge Objects have designed systems that are able to proactively adjudicate claims against comprehensive best practice clinical and coding rules in real time. This means we are able to stop invalid claims before they are paid, as it is very time consuming and costly to recover paid claims retrospectively.”

Liebenberg says it is unfortunate that the intricacy of claims processing means it is not generally easy for healthcare consumers to understand.

“Coding and claims handling structures were unfortunately not designed to be understood by the patient, and when a claim is found to be invalid all the patient is told by the doctor is, ‘Your medical scheme did not pay’. While we engage with healthcare providers on potentially problematic claims, there is also a need for medical scheme members to understand the importance of doctors following the correct claiming process.

“Effective claims handling processes must include effective risk management protection. This enhances value for medical scheme members, as it protects the funds available to cover their healthcare needs and helps to reduce the need for increasing membership contributions,” she concluded.


Share This