Managed Healthcare

PPSHA’s managed healthcare encompasses clinical and financial risk management of healthcare with a view to facilitating appropriateness and cost effectiveness of relevant health services.

We provide integrated managed care services, which include the management of adverse claims experiences for a scheme.

This begins at the:

• analysis of variance to budget
• the contributing factors to the variance
• an understanding of the complexities, within the response to address the adverse trend
• avoiding the bubbling or waterbed experience effect so it does not drive another variance

We understand that we need to constantly evolve and get better, as our client Schemes and their members continue to evolve and grow. Our driving force is to provide excellent service and advice, to support the sustainability and growth of the Scheme.

While we take a blue skies approach to innovation, we follow a brown mud path to delivery. We believe that the Scheme can be kept healthy by managing its claims ratio optimally. This is done by applying scheme benefits and tariff rules appropriately. In addition, clinical risk management ensures that members receive the appropriate treatment and care.

We offer the following Managed Healthcare Services:

• Hospital Benefit Management
• Clinical Auditing
• Clinical Committee Review
• Clinical Risk Reporting
• Network and Provider Contracting
• Provider Negotiations
• Disease Risk Management