| Advantages | ||
There are numerous advantages to using Eminance
for
managed care, simply because the process is automatic, once you have tagged the patient
with the category or type of managed care. They include;
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| Authorizations | ||
Eminance caters for managed care pre-authorization or authorizations on a number of levels. Each dependant can have their own authorization number for any period of time. In addition, a procedure, medicine or medical aid may always require an authorization. Simply tag the patient or authorization type, and if the authorization is not on file, the system will prompt you to enter the number. The number can then be printed on the statement, and if you are submitting the claim via EDI, the number will be automatically transmitted. |
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| Capitation | ||
| When you embark on a capitation scheme, it is important to
gauge whether the venture is economically viable. Eminance allows you to tag patients
with a capitation limit, and to then bill the patients normally. At any time you can check
the viability and cost per patient, or group of capitation patients. Eminance
caters
for both individual capitation or group capitation - along with fixed fee billing. It is a
versatile system that caters for almost every managed care option - allowing you to
monitor the movement. Capitation is supported for both the Vat receipts and invoice
method, to ensure your accounting conforms to generally accepted accounting principals. On the basis that you receive a fixed fee per patient for a period, you can post the payment against the patients account and inhibit any EDI transmission or statement run. This gives you a more accurate picture of the costs involved, allowing you to make a more informed decision. |
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| Care Levels | ||
| Detailed managed care data is essential to a practice in determining whether it is economically viable to continue on a managed care scheme. Medical aids gamble that providers who are on managed care schemes can manage and care for their members for less money that what it currently costs them. One of the strategies of managed care is that there will be shift away from expensive specialists to lower paid general practitioners. This strategy regulates the use of high cost services, and at the same time gives the GP the incentive to provide more of the patients health care. Patients normally choose their doctors from a list of doctors provided by the medical aids. However, the practitioner must be able to ensure that the care levels are within the monetary range provided. The program allows this monitoring by flagging a patient if their capitation has been exceeded, or if on another type of managed care program, via statistical reports. | ||
| Co-payments | ||
| Co-payments can be automatically generated per patient at the point of posting transactions. While the program caters for all types of medical aid levies, a co-payment is the nominated difference between the scale of benefits amount and the fixed fee amount. The program allows you to establish a procedure or treatment based on a fixed fee, and any amount in excess of that fixed fee automatically is for the patient account. | ||
| Eligibility | ||
| Without doubt, medical care management is in a high risk category. This risk starts from the minute the patient is entered onto the system, to the time that the account is rendered. There are numerous events which contribute toward the risk - ranging from valid membership numbers through to eligibility schemes. Because patients in a managed care plan can change frequently, it is essential to verify both the eligibility of the patient and the services covered. The program caters for both these scenarios. The first is via the membership mask which pre-validates the membership number, while the latter is via the authorization and tagging system. The medical aid levies allow you to exclude or include certain procedures and tariff codes from a specific medical aid. Therefore it becomes easy to identify that a specific scheme will not pay (for example) a diving medical - and if that procedure is undertaken, that it would be for the patients account. | ||
| Formulary | ||
| Our program allows an unlimited amount of formularies and schemes. In turn, each scheme can link up to three formularies and each medicine apply to up to three formularies. This ensures that a patient linked to a specific scheme is dispensed medicines from the formularies in the medicine files. Once the medicines and schemes have been updated with the formulary, the process is fully automatic. In addition, there is expensive reporting on the medicines dispensed within that formulary, along with key indicators such as profitability, movement and usage. | ||
| Referral To | ||
| One of the requirements of managed care is that pre-authorization must be in place before a patient is referred to a specialist for an expensive procedure, such as a CAT scan. Some managed care companies have a system where pre-authorization is predetermined from an existing number list, provided that the referral is medically justified. In both cases the program keeps track of the referrals and holds a complete doctor referral register. Added with the fact that each patient can have a set diagnosis, reporting and auditing of the referrals becomes a easily managed task - very important since the risk is held in the practice. Using the Eminance patient clinical notes, detailed reports can be kept on file and mail merged to the referring doctor. | ||
| Referral From | ||
| Specialists handling referrals have the ability to tag the patient as a referral and to generate reports based on incident reporting and referral rates. Emphasis is placed on the authorization and membership number accuracy and the ability to extract reports based on these key indicators. | ||
| Reporting | ||
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