MANAGEMENT OF HOSPITAL COSTS

MHS HOSPITAL UTILISATION MANAGEMENT  (HUM)

DEFINITION
The HUM programme authorises and monitors in-patient treatment to ensure it is appropriate and cost-effective. It keeps track of all hospital in-patients and monitors care via pre-authorisation, case management, discharge management and account review. The norm is established by means of the Hospital Profiling Programme. Interventions take place in instances where there is a deviation from the norm.

FEATURES

• Pre-authorisation: All non-emergency cases are authorised before admission to hospital.

• Confirmation: All cases that have not been pre-authorised are authorised on admission to the hospital. Membership is confirmed, and the hospital is given an Authorised Amount and Length of Stay, according to pre-established norms.

• Case Management: All cases varying from the norm are managed as follows:

• Review of preliminary accounts,
• MHS doctors and nurses discuss cases and/or admissions with hospital case managers, nursing staff and attending doctors,
• Discharge Management: Where patient rehabilitation and prolonged nursing care are called for, arrangements are made for appropriate step-down care,
• Account Review: Accounts that vary from the norm are scrutinised by trained nursing and medical staff.
• MHS Electronic Claims is an optional, but valuable adjunct to the Account Review process.

• At the pre-authorisation stage, permission may be declined for inappropriate procedures, or more appropriate procedures suggested. This results in a direct saving.

• Case Management, Discharge Management and Account Review all focus on cost-effective and appropriate care.

• Providers are alerted to the high cost of certain treatment modalities and are encouraged to consider each management decision carefully.

• Provides the medical scheme with excellent management information, e.g. caesarian section rate,

• Focuses the hospital intervention strategy on the most profitable areas, thereby optimising the cost-benefit of such interventions,

• Monitors the quality of care received and assists in the measurement of outcomes,

• Assists medical schemes with the design of benefits, based on the information obtained.