Hospital Benefit Management

Pre-authorisation | Emergency Admissions | Call Centre Contact Numbers

FREQUENTLY ASKED QUESTIONS

Who is MSO?

MSO is a privately held company which provides risk management and disease management services to over one million beneficiaries throughout Africa, Europe and the United States. It is unconditionally accredited as a managed care organisation by the South African Council for Medical Schemes and services to members are rendered by clinically qualified staff.

What does the Hospital Benefit Management entail?

The program consists of three interrelated services, namely pre-authorisation, case management and clinical audit.

It begins with the pre-authorisation of all hospital admissions. The call centre is manned by qualified nurses that follow specifically designed medial protocols and guidelines to apportion the appropriate level of hospital resources in relation to the clinical needs of the patient, and monitor the quality and cost of care provided for all hospital admissions.

Case management commences on admission to hospital for all major surgery and serious illness. All case managers are registered nurses with many years of practical experience. To ensure optimal recovery, the appointed case manager will liaise with the doctor or specialist to ensure that all patients receive the best possible and most appropriate care. Another function of the case management process is assisting members with discharge planning, post-hospital care, as well as the possible transfer to rehabilitation and convalescent facilities.

All hospital claims are assessed retrospectively against the pre-authorisation budget. Qualified clinical auditors identify variances, and negotiate discounts or reductions with the hospital.

How does hospital benefit management benefit the member?

The purpose is to ensure that members and their beneficiaries receive quality care, delivered in the most appropriate setting through a process that encourages effective, efficient and consistent utilisation of healthcare services with the resulting appropriate allocation of resources.

Why is pre-authorisation necessary?

Pre-authorisation ensures that the proposed treatment or procedure in hospital is the most appropriate and cost-effective. Clinically based evidence (medical protocols), will be a critical factor in the scheme’s decision in consultation with the scheme's Clinical Advisors, to either limit or deny funding or propose alternative appropriate treatment for a proposed procedure. This provides you with the peace of mind that all expenses incurred during your hospital stay are approved and covered, whilst at the same time receiving optimal care.

What benefits require pre-authorisation?

  • Any procedure or treatment that requires admission to hospital, E.g. Tonsillectomy, back surgery, gynaecological procedures, etc.
  • Specialised radiology in and out of hospital, e.g. MRI and CT Scans;
  • Disease management programs such as oncology, peritoneal dialysis, haemodialysis and transplants;
  • Home nursing, admission to a step-down facility and clinically appropriate rehabilitation;
  • Internal prostheses, E.g. stents or hip prostheses;
  • Maternity admissions and confinements;
  • Appliances related to hospital admissions, E.g. leg braces, crutches, etc.
  • Injury on Duty (IOD) cases, which require hospital admission. This ensures that the hospital is aware that the claim will be paid by the
  • Commissioner for Occupational Injuries and Diseases (COID).

How do I pre-authorise?

The entire function is rendered through one unique share-call number, thereby providing ease of access to you, the member. Please refer to Call Centre Contact Numbers for your medical scheme specific number. In the case of an emergency situation, you or a family member may pre-authorise the admission on the first working day after being admitted. The Scheme will then be responsible for the account based on the scheme’s rules.

What is clinically based evidence (Protocols)?

Pre-authorisation requests are evaluated against internationally recognised protocols which are based on actual proven clinical evidence to ensure that you the patient receive the most appropriate care for your condition, in the most suitable facility at the most cost-effective price.

When do I require pre-authorisation?

For non-emergency admission to hospital, the pre-authorisation must to be completed before admission to hospital, preferably 72 hours before the procedure is to be performed. Emergency admissions may be authorised at the time of admission or the first business day following the admission. You will be provided with an authorisation number and a fax/e-mail copy of the approved authorisation is forwarded to the specified hospital for their records.

Why are second opinions sometimes requested by MSO

For non-emergency spinal and joint replacement surgery for example, it may be necessary to request the opinion of a second medical specialist. The reason for this is to ensure that the surgery is clinically necessary and conservative treatment i.e. physiotherapy is no longer appropriate. An example would be a request for a spinal fusion at multiple levels where no conservative treatment has even been utilised.

Although second opinions are generally only requested to confirm the appropriateness and clinical necessity of a proposed treatment or care, it also confirms a patient’s fitness for surgery. A written evidence-based protocol underpins the decision to request a second opinion and, if indicated, to deny access to benefits

Why do I need to be fit for surgery?

All schemes have a responsibility to alert members to the fact that their health should be in the most favourable condition before undergoing scheduled elective surgery. Anaesthesia poses a high risk in patients whose cardiac and respiratory fitness is not optimal. Therefore, in these instances, pre-determining fitness for surgery is key to a safe and successful operation and ensuring the best clinical outcome of your planned procedure.

What information do I need when I phone for a pre-authorisation?

  • Membership Number
  • Patient’s name and date of birth
  • Doctor’s name and practice number
  • Name of hospital where the patient will be admitted
  • Procedure to be performed and ICD10 codes
  • Date of admission

What is Case Management?

Case Management, together with the care and supervision of your treating doctor, facilitates optimum treatment for all hospital or related incidents at an appropriate facility and level of care. At the same time, clinical protocols and cost-containment measures are being applied to control the financial risk of members and the Scheme. Only clinically qualified network case managers are utilised, who visit hospitals with the full co-operation of the hospital in all major towns and cities in South Africa. 

They will monitor and visit patients with high cost and complicated admissions while the patient is still in hospital to ensure that the member is receiving the most appropriate care in the best possible facility.

What is Disease Management?

Disease management is designed to focus on members who need assistance managing a chronic disease. The program is managed by registered nurses with clinical expertise in disease management, supported by the scheme's internal medical team, who co-ordinate the clinical case needs as well as the program participation of members. Education, self-monitoring and access to medical resources and community information are a focal point of the program. A number of chronic diseases are managed to prevent and control hospital admissions. If you have a known chronic condition it is in your best interest to register on one of the following wellness programs:

  • Diabetes Management Program
  • Asthma Management Program
  • Hypertension Management Program
  • Psychiatry / Mental Wellness Program
  • Oncology Management Program

What are the benefits to you to register?

MSO’s support team will liaise with you regarding your treatment to ensure that you receive the most appropriate and optimum treatment. You will receive guidance and literature on how to live with the disease and will be provided with mechanisms to assist you in the prevention and management thereof.

How do I register on the program?

MSO, in co-operation with your medical aid, will through their data management system, identify those members who will benefit from the programs offered and a clinical consultant will contact you telephonically to register you on the program. You will be given a contact person’s details who you can call when needing further information regarding your disease. Alternatively, to speed up the process, you may also contact MSO to register on the program.

Information that can prove helpful to you in managing your disease will be sent directly to your postal address. This includes healthier eating habits, fitness programs and answers to some questions you might have. The Disease Management Call Centre can be contacted on Tel. +27 (0) 11 259 5000, Monday to Friday between 08h00 and 17h00.

MSO will assist you to set and maintain goals for a healthier lifestyle by providing telephone counseling and literature on the management of your specific disease or condition e.g. dietary advice for obese patients with cardiac conditions, advice on effective use of an inhaler for an asthmatic patient, etc.