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Hospital expenditure represents the
largest component of overall healthcare
expenditure in medical schemes. As such,
medical schemes need to ensure proper
management and non-abuse of these
benefits due to the significant and direct
impact it has on the Scheme’s sustainability
and future contribution increases.
 Selfmed has appointed the Medical
Services Organisation (MSO) as its
hospital benefits managed care provider.
MSO employs clinical experts and has
adopted well-researched evidence based
protocol and authorisation tools to safeguard
against undue hospital admissions
and the associated costs. These tools are,
however, not only aimed at reducing costs
to the Scheme, albeit a result thereof, but
serves to apply methodology that has
members’ best interests at heart.
Members may, however, experience
the MSO intervention as more of a
burden and frustration as opposed to a
benefit. For example, any member who
requires a joint replacement procedure,
will be subject to a second medical
opinion review, i.e. complete medical
evaluation by an independent doctor
referred by the Scheme, and a fit-for surgery
review. Members trust their own
doctors’ opinion and may consider this request an unnecessary
waste of time and money.
Yet in many instances
such additional evaluation
has assisted in diagnosing
new or unconfirmed
medical conditions of
which a beneficiary and
his/her physician were
not previously aware. Just
recently, a member who
was declared fit for surgery,
was newly diagnosed with
diabetes and would have
posed a severe risk, had
the surgery been approved
without further intervention.
BODY MASS INDEX
Body mass index (BMI) is a very
specific protocol that is increasingly
being applied by MSO, in particular
when requests for joint replacements
are received. It is widely accepted in
the field of medicine and wellness
that when a person has a BMI higher
than 30, such person would have a
significantly increased risk of various
chronic ailments, incl cardiovascular
disease, pulmonary diseases,
diabetes type II, gallbladder disease, osteoarthritis and gout. Obesity also
impacts life-expectancy as per the
chart above that was published on the
website, www.thelancet.com on 28
March 2009 and based on European
Union mortality rates in 2000.
In view of the above, Selfmed
members need to note that certain
procedures, in particular joint
replacements, will not be approved
for benefits if the beneficiary’s BMI
exceeds 30. The Scheme supports this
protocol as the objective thereof is not
to avoid payment, but to enable and
promote beneficiaries’ health well-being.
LIMITS ON
HOSPITALISATION FOR
LAPAROSCOPIC PROCEDURES
The Selfmed options’ benefit brochures
describe benefits for hospitalisation to
be unlimited. This is true insofar any
general monetary limit for hospitalisation
is concerned. In terms of certain
procedures, specifically laparoscopy
procedures, the Scheme will respect
members’ decision to have a procedure
done through laparoscopy as opposed to
the conventional method, yet reserves the
right to limit the costs of such laparoscopy
procedure to that of the conventional
equivalent. Members are urged to discuss
and confirm if any limit will be imposed
at the time of pre-authorising their
hospital procedure.
Members are also reminded to take
note of the co-payments applicable to
medical investigations done through
laparoscopy, as specified in the Selfmed
options’ benefit rules (not applicable to
Selfmed 80%).
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