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. Real-time electronic claims processing services (performed on all benefit categories)
Data integrity validation – a comprehensive list of validations (this ensures that claiming standards are achieved), e.g. missing/invalid product or member number.
Eligibility management - a comprehensive list of validations e.g. claim rejected when a member has been suspended or a provider is not valid.
Medicine utilisation management - a comprehensive list of validations e.g. claim rejected when a premature claim repeat is attempted or excessive duration of therapy is claimed.
Clinical management (DUE/ DUR) - a comprehensive list of validations e.g. claim rejected when the maximum daily dose for a medicine is exceeded or there are critical drug interactions.
Price management - a comprehensive list of validations e.g. claim value adjusted when the incorrect product single exit price, reference price (FRP, MRP or MMAP) or dispensing fee is claimed.
Real-time benefit validation - through a real-time switch-out to the scheme or administrator e.g. when a member is out of benefit the scheme won’t reimburse the claim.
2. Client support services
- 117 staff in total (with 35 health professionals);
- Helpdesk – available 7 days a week;
- Dedicated client support teams;
- Dedicated provider relations team;
- Ad-hoc patient approvals e.g. extended medicine supply for overseas trips;
- Provider communication by real-time messages, web, e-mail, fax and through provider switch organisations, Switch™ and Healthbridge;
3. Supplementary services
- DSP and provider network management;
- Formulary design and management;
- Development and maintenance of reference price lists;
- Price and product file maintenance;
- Random paper audit function;
- Pharmacoeconomic and Clinical/Pharmacological consultation expertise;
- REF reporting with ICD-10 functionality;
- Clinical protocols and formularies under guidance of our established and independent Pharmaceutical and Therapeutics Committee.
4. Information services
Mediscor delivers a comprehensive reporting and data analysis service through:
- Our interactive reporting facility, the Mediscor Analyzer . The Mediscor Analyzer enables clients to view their results on-line and facilitates “drill down” capabilities to view for e.g. medicine expenditure results,industry comparisons and profiling.
- Ad-hoc analysis and reports as arranged from time to time.
5. Consulting services
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.
6. Doctor claims
Within the South African industry, Mediscor receives claims from all Switches e.g. HealthBridge; Switch (QEDI and Mediswitch); Medilink and all doctor bureaus.
Mediscor applies rules in term of the registered scope of practice
regulated for each provider group , has the ability to process all provider procedure claims and to apply standard tariff rules pertaining to the dispensing of medicines
7. Paper claims
Mediscor has developed several mechanisms through which we can receive paper claim information that is submitted directly to our medical scheme clients.
Receiving paper claim information that is submitted through the Mediscor PBM system ensures that we carry a comprehensive patient history
and facilitates accurate reporting and patient profiling.
8. PMB and Chronic authorisation services
Access to chronic and PMB medicine benefits are managed through systems-driven automated chronic medicines lists, supported by Comprehensive pre-authorisation and review performed by our ChroniLine™ department.
9. Mediscor compliant pricing pharmacy network
The recently established Mediscor Compliant Pricing Pharmacy Network consist of over 500 individual pharmacies, pharmacy groupings and courier/postal pharmacies who have all undertaken to charge a maximum of SEP + the “Regulated” R26/26% fees, without any additional administration fees, to the members of our contracted medical schemes.
This network is available to all medical scheme clients’ members, ensuring that all members enjoy a known and hassle-free medicine claiming experience.
Last Update: 07 July 2009