Oncology Management Programme

The Oncology Management Programme due to its complexity and variability is a disease-specific patient-management programme covering all aspects of cancer treatment, excluding complications and unrelated comorbidities, amongst medical scheme members.

Patients or their practitioners are required to submit details of the treatment plans designed for their patients and such treatment plans are evaluated bearing in mind –

  • Clinical protocols for the appropriate treatment of the cancer;
  • Regulations published under the Medical Schemes Act regarding Prescribed Minimum Benefits, and
  • The Medical scheme’s Rules and Benefit structure

MHS will inform the Scheme’s administrators of treatments and other interventions authorised by MHS on behalf of the Scheme for reimbursement in whole or in part by the scheme.

The objective of the Programme is to strive, within the constraints of legislation, Regulations and Scheme Rules and Benefits, to ensure optimal therapy that is rational, appropriate and cost effective for all patients requiring oncology treatment.
In order to fulfil its service obligations to the Scheme, MHS undertakes to perform the following tasks on behalf of the medical schemes:

  • Enrolment of patients on the Oncology Management Programme;
  • Evaluation and agreement of Treatment Plans with the attending practitioner: Radiologist/Oncologist;
  • Consultation with a specialist oncologist panel when necessary;
  • Consultation with relevant industry body such as: SAOC/ ICON etc;
  • Authorisation / preauthorisation of appropriate treatment benefits;
  • Evaluation and registration of PMB status;
  • Coordination with HUM and Medicine Management Programmes and when appropriate with wellness and the scheme’s other Designated Service Provider programmes - As cancer patients are often admitted for treatment or surgery to the hospital it is essential that these two programmes are well integrated;
  • On-going monitoring and updating of Treatment Plans with consideration of evidence based clinical protocols;
  • Consideration of ad hoc / supplementary supportive and non-routine treatment modalities; for example; for nausea and vomiting, etc.
  • Authorisation / pre-authorisation of home nursing and hospice care;
  • Evaluation and screening of Ex Gratia requests and Appeals;
  • All the above deliverables are managed with consideration of appropriateness, cost curtailment where possible, negotiating of better rates and management of PMB versus non-PMB oncology patients; and
  • Reporting to the Management and Trustees of the Scheme in the following format:-