Since the year 2000, non-healthcare expenditure has increased by 217.9%, far exceeding the Consumer Price Index (CPI). This has consequently driven up premiums for healthcare consumers, causing many South Africans to question why they are paying so much more for their medical scheme membership each year.
"A large portion of these non-healthcare costs can be attributed to an upswing in administration expenditure," explains Wilma Liebenberg, CEO of Knowledge Objects Solutions (KOS), a South African-based company that specialises in effective global risk management and higher automation solutions within the healthcare funding industry.
According to Liebenberg and her team, the solution to the growing challenge of keeping non-healthcare costs down within the industry is simple: lower non-healthcare expenditure by decreasing administration costs. "There is much redundancy and inefficiencies that have arisen in the current system of healthcare administration in terms of the time, costs and personnel necessary to process applications, claims and grant authorisations.
"Implementing 21st century solutions that provide fully automated, customised software for the healthcare funding industry will address the glaring inefficiencies in the traditional model of managed healthcare.
"The company is one of the first of its kind in South Africa that provides its clients with sophisticated software to make operations more efficient within the healthcare administration industry. It does this by effectively 'removing the middleman' from the administration side of the equation and drastically bringing down the administration burden on medical schemes."
It provides clients with advanced artificial intelligence capabilities using clinical and business intellectual property that automates complex rule-based decisions common to funders of healthcare. "This means that non-technical people can write rules in English, which the system translates into code and then makes a 'yes or no' decision. Not only does this expedite the process of submitting claims and obtaining pre-authorisations, but it also helps root out fraud in the industry."
As a major leader in the automation of administrative processes in South Africa, it has expanded into the Pacific and Middle Eastern markets. "In 2008, we sold our pharmaceutical benefit management functionality to the largest open medical scheme in South Africa under a restraint of trade for three years, during which time we have redeveloped and restructured the software so that it is customised for the local market.
One healthcare funder that has benefited from the services offered by KOS is Resolution Health Medical Scheme (Resolution Health), which went live with the system at the beginning of this year. According to Mark Arnold, principal officer of Resolution Health, providing more healthcare cover for every rand contributed by members is one of the main goals of the Scheme. "Ideally, we want every premium paid by a member to go towards their specific healthcare needs and not towards pushing paperwork," he concludes.
