Medware: Product FAQ's

Seamless assessing

Existing Administrators using Medware do not organise their claims departments according to scheme or option.

The system is multi-administrator, multi-scheme, multi-option, and all benefit rules are held in user-maintainable tables (parameter lists). Claims data-capturers do not have to be aware of scheme- or option-specific rules, and error messages can be set up to prevent lesser skilled data capturers/assessors from overriding messages by staff security levels.

The system has been designed in such a way that the data capturing/assessing function can be distributed across wide area networks, facilitating assessing from home or regions.

How do you handle exclusions and/or waiting periods?

Currently we use our comprehensive case management system to load waiting period cases for these people. We load a Diagnosis code and some free text. The system will display a message for the assessor that such a case exists. The assessor then has to evaluate the claim accordingly and decide to pay or reject.

Are you able to store documents electronically?

The Medware system comes with an integrated comprehensive scanning solution which handles the acquisition, storage and presentation on demand of all types of documents, paper and electronic.

These include paper claims and correspondence, claims statements, automatic letters.

These images are available to authorised staff, and are visible to authorised users on the website.

Does your system handle Electronic data and interfaces?

It does so in various forms:

Real-time Electronic claims:
The Claims "Engine" within Medware is a rules based, parameter driven subroutine (object), that is callable from many points:
Batch
On-Line
Internet
Switches
SMS

Switched claims automatically reserve relevant benefits, and are ready for payment immediately. The system is able to receive these claims 24 hours a day, 7 days a week. Standing facilities are available in the event of connection failures. This has however proven to seldom exceed 0.5% of all switched claims. Response times on switched claims are sub-second.

Development is underway to receive switched claims from Healthbridge, as well as switching medicine claims to MediKredit for price and clinical verification.

Batch Claims:
Medware accepts electronic claims in batch from various Pharmaceutical Management Companies. The receipt of batch claims may be enabled at short notice.

Payment:
The system caters for cheques, and direct deposits and collections via ACB and Persal.

Contributions, eg "Nedinform":
The system handles downloading of reconciliation information from a number of banking institutions, including Nedbank, Absa and Standard Bank.

Email of Invoices:
Medware will email members and providers a mini-statement each night showing claims received and processed.

All statements are available on the website, and can be downloaded from there.

Emailing of statements to members and providers is under development.

Internet Access:
Medware offers a comprehensive 24x7 website, allowing authorised members, providers, groups and brokers access to most data from the real time databases. Access, and depth of data available, is controlled by indicators on Broker and Group records.

Managed Health Care Interfaces:
Medware currently generates the files as required by MHS and is able to link with other managed health care providers or re-insurance companies.

Case Management:
The system has a comprehensive case management system, and caters for import of cases from Sanlam Health. QA Care cases will be programmed, making use of existing code.

Pro-Sort Address Details:
This is not available but can be achieved with light system modification (3 weeks).

Persal:
Medware generates the correct files for upload to Persal.

Does your system handle the "new age" plans?

Medware handles savings options and thresholds, and the origin of benefits is stamped onto assessed claim lines. The decision from where the benefits are taken is automatically handled by the rules system.

Since all claims contain rich accounting information, the MIS tools can be effectively used to summarise and drill down into claims information.

More clarity is required regarding payment of claims on a cash as well as credit basis, but the system will handle pre-funding of savings balances, as well as payments based on actual monies receipted into savings accounts from contributions.

How is Invoicing and Receipting handled?

All contribution tables contain a breakdown of total contributions, and raisings and reconciliations of receipts is done and held at member level, regardless of how the contributions are received.

Since contributions raised and received are held in detail at member level, it is possible to view the reconciliation at group, option and scheme level.

Claims Debtors and Contribution accounts are held as open items.

Can Medware process a Capitation type product?

A better understanding of these requirements would be necessary, but the system can handle "pre-paid" claims, and capitation payments to provider groups will be handled in the same way that brokers' commissions are handled - ie a formula will be used based on the number of members assigned to providers, modified by factors such as actual usage and profitability.

Customisation may be necessary to achieve the client's exact requirements.

Will my membership number change if I move plans?

You will be given only one membership number. The system allows transfer of a member between options within a scheme without a change to member numbers, and the claims processing engine correctly calculates benefits based on conditions prevailing at date of service. Rules may be changed at any time, and can last as little as one day in duration.

What access will my broker have?

The system contains a comprehensive Broker commission and membership status tracking system, which is Internet enabled.

Authorised Brokers have limited to complete access (controlled by indicators) to only their own members. Provision is made for a hierarchy of workers.

Submission of applications via e-mail and web has been signed off in pilot.

Do you record all changes made?

Medware has a comprehensive online Audit system. All changes to master files are logged in audit trails, and information stored includes who, when, which programmes, before and after images.

What type of Management Information does the system include?

Medware exports data into PowerPlay cubes for drill-down access by Information Managers.

These cubes are constantly under refinement, and are driven by clients' needs.

Reports - standard reports are produced on request, daily, weekly, monthly. All clients' reporting requirements not yet handled will be specified during due diligence, and will be included with Medware when deployed or shortly thereafter.

What accounting system do you use?

Medware does not handle scheme general ledger requirements internally, but instead interfaces to a variety of standard accounting packages. As part of the due diligence process, NHA will work with the client to interface to the client's choice of packages, and may, at the client's request, recommend packages with which our clients have had great success.

How long does it take to go live?

The target LIVE data is usually determined by signature of the contract and is typically three months from conclusion of contract until LIVE.

After contract signature, NHA will conduct a more detailed on-site investigation which should last between two and four weeks. This phase allows our team a more thorough look at all the current processes, procedures, paper trails and data availability, cleanliness and richness. This will help us to determine any "gaps" and therefore what customisation is required. This phase includes a technical inspection of all equipment and infrastructure to determine any other hardware and software requirements.

As output to this phase, a detailed project plan will be developed highlighting the areas of customisation, data take-on, training, hardware and software required.

Immediately after this NHA will begin with a data take-on from the old system into Medware. We would require detailed data maps and availability of existing data, and would work with existing IT people ...

The last phase pre-live is dedicated to training, running in parallel including payment runs, detailed data cross checks between old and new, and further customisation. In these months all the "missing" hardware and software to enable the Medware system will be configured and installed.

How is security maintained?

Technical Security:
The main server and image servers can be located behind existing firewalls. The information supplied for the web is not directly exposed to the internet, but is requested and delivered through defined sockets (similar to ODBC) between the web server and HP3000 and other servers as required.

Access to the HP3000 is via the proprietary logon security system and will only be available from the LAN.

The website can make use of certification and https encryption at very little cost and inconvenience to web users.

Medware Security:
All claims are fully assessed against a set of prices or tariffs. Claims that exceed those prices (by a user-defined percentage) are highlighted, and require assessor intervention.

All forced claims are logged as such, along with the reasons why they were forced. Staff are assigned a user level, and error messages are pegged at certain levels, enabling fine control over staff functions and capabilities throughout the system.

All changes to data are logged along with date time and user, before and after values, and these form a powerful tool for managing the audit process.

Reports exist that highlight outlying transaction values (higher than threshold claims, etc).

How is training handled?

Training will take place on site, and will form part of implementation and customisation.

Our philosophy here is to train all staff to use Medware in an offline, dedicated environment, and we would request the client to provide facilities for 8 - 10 staff per session.

Trainers will be drawn from NHA's 100 staff members.  User manuals exist, and are used as work books during training, and are retained by the staff.

Onsite IT personnel act as backup and reinforcement following training.

We have dedicated user liaison staff in Gauteng, and these people rove between sites monitoring user access and usage of Medware and attending to ongoing training requirements.