Presentation on theme: "1. 2 Company Background Pioneer & time proven Managed Care Organisation (MCO) in Malaysia Third Party Administrator (TPA) Established on 15 th Nov2001."— Presentation transcript:
2 Company Background Pioneer & time proven Managed Care Organisation (MCO) in Malaysia Third Party Administrator (TPA) Established on 15 th Nov2001 Specialist- dedicated core business activity (not a side business) Managed by insurance experts and supported by full time medical doctors
3 Companys Goal –To be Malaysias leading Health Care organization. –To be recognized for Excellence. –To be respected for integrity, initiative and involvement. –To be a caring organization. –To Practice the Highest Degree of Professionalism.
5 BOARD OF DIRECTORS Abdul Aziz Nor (LLB Hons Essex University, London) Chairman S.Gopinath Group Executive Director Dr. Madhavan Nair Director Medical Dr. Avtar Singh Director Medical (Penang)
7 Our Responsibilities, Your Advantages We : Compare and choose a health plan to your needs. Understand your managed care benefits. Resolve claims problems and billing disputes. Select Doctors, Hospitals and Clinics. Tackle Doctor/Patient communications issues. Give reports every month to the Employer on the Date of Visit, Clinic visited, Illness, No. of MC Days and Amount spent. Give reports on Pattern Of Illness and Eligibility Vs Usage. Verify / Validate Clinic Bills. Issue Cheques to the multiple clinics. Issue Guarantee Letters (24 Hours) Educate the Employees. Communicate in Medical language. Reduce Cost without fixed rates. Wellness Program Save your valuable Time and Headaches.
8 Functions & Operations 24- hour helpdesk line Roadshow for issuance of cards Appoint and select panel clinics Administrating claims Monitoring claims Generating management reports based on clinic claims Review of Clinic Bills
9 How the cost will be reduced ? Review of Medical Bills Monitoring of Clinic Bills Querying the Clinics/Doctors Supplying the medicines for Long term Illness. Wellness Program Monitoring the frequent visits report. Reduce the hidden cost of the client.
11 OUTPATIENT (CLINICAL) SCHEME
12 Managing Outpatient Scheme on Fixed Cost Basis
EMPLOYEES Panel Clinics/ Specialist Submit Reports Submit Claim Forms & Bills Outpatient Benefits Present Rakyat OP card and get treatment Pay Clinic Bills Monthly Payment Managed by P.C.S.Rakyat Sdn Bhd ABC BERHAD
OUTPATIENT CARE BENEFITS Plan Individual Plan Family Plan Single Parent GP Clinic Service for Outpatient Consultation including Covered NIL Covered Child : up to 21 yrs old Drugs Basic Diagnostic tests including Lab Tests/X-Ray/ECG Childhood Immunisations URGENT/EMERGENCY CARE Nationwide Emergency Health CoverageCovered 24 hours Provided by GP or Specialist on an Outpatient Basis According to Benefits Limit Specialist Visit (referred by Panel Clinic) Specialist Care & Diagnostic ServicesCovered in Full Specialist Consultations, Diagnostics Procedures & Recommended Drugs via Specialist Consultant P.C.S. RAKYAT OUT-PATIENT SCHEME
15 OUT PATIENT SCHEME EXCLUSION CLAUSES The exclusion of the Rakyat Out Patient Programme are as follows: Pregnancy and abortion Family planning services, sterilization procedures and work-up or treatment of infertility Treatment, examination and lab tests not ordered by Medical Practitioner Traditional and alternatives therapy such as Acupuncture, Homeopathy, Bomoh or Sinseh Treatment Injuries due to insanity or self-inflicted AIDS (Acquired Immune Deficiency Syndrome) & HIV related Diseases Travel & Adult immunization including Hepatitis Direct sales nutritional products Treatment to improve the psychological, mental or emotional well-being
16 EXCLUSION CLAUSES Cosmetic Surgery for purpose of beautification or plastic surgery including sex change surgery Dietary supplements, appetite, suppressants, anabolic steroids and cosmetics products Expenses which should be claim under SOCSO / Workmens Compensation Scheme Medical examination, required by third party such as Pre-employment examination, Vehicle licensing examination & regular screening profiles Telephone, fax charges, private nursing, lodger fee, administrative registration fee & nonmedical personal items Treatment for recuperative purpose as a result of mental fatigue, rest cures or sanatorium care, drugs addiction or alcoholism, communicable diseases requiring by law isolation or quarantine in the event of an epidemic Sonotron Therapy, Heart scan & new investigative modalities non approve by Ministry of Health Malaysia, Academic, Medical Institutions, or renowned medical authorities such as FDA of the USA. Maximum supply of Medication is up to 1 month & if a member needs medication more than the said periods, he / she has to consult P.C.S Rakyat who will make the necessary arrangement for him / her. Vitamin / food supplement / Orthopaedic appliances / Medical equipment. Any changes can be discussed
Date of Visit NameEmpl No. BranchDeptRShipClinicDoctorDiagnosisMC days Charges 01/04/04C.Sivarajan12048P.KlangHRPrincipalKlinik RaviDr. Azhar Fever/Cough/ Cold /04/04 Hamidon Buang 65032JohorADPrincipal 02/04/04NorhayatiSpouse Klinik Deepa Dr. UshaTonsilitis /04/04 Sulaiman Bin Alimon 76800PenangADPrincipal Klinik Famili Dr. JoeDiarrhoea /04/04Tong Fei Loong80963KLGN Principal Klinik Public Dr. Chuah Rashes Rita87600KLACPrincipal Klinik Amar Dr. AmarEye Infection Mohd Idris17821JohorADPrincipal Klinik Nik Isa Dr. AisahMigraine Abd Kadir62145PenangHRPrincipalMedivironDr. TanBronchitis /04/04 Md Elai Bin Fadzil 23456JohorHR Principal Klinik Segara Dr. Sasi Back Ache/Body Ache Monthly Clinic Claim Report-April2004 TOTAL Sample Report HR- Human Resource AD - Administration GN- General
Date of Visit NameEmpl No. BranchDeptRShipClinicDoctorDiagnosisMC days Charges 01/04/04C.Sivarajan12048P.KlangHRPrincipalKlinik RaviDr. Azhar Fever/Cough/ Cold /04/04C.Sivarajan12048P.KlangHRPrincipalKlinik RaviDr. AzharFever /04/04C.Sivarajan12048P.KlangHRPrincipal Klinik Famili Dr. JoeDiarrhoea /04/04C.Sivarajan12048P.KlangHR Principal Klinik Public Dr. Chuah Rashes C.Sivarajan12048P.KlangHRPrincipal Klinik Amar Dr. AmarEye Infection C.Sivarajan12048P.KlangHRPrincipal Klinik Nik Isa Dr. AisahMigraine C.Sivarajan12048P.KlangHRPrincipalMedivironDr. TanBronchitis Monthly Employee Claim Report-April2004 TOTAL Sample Report HR- Human Resource AD - Administration GN- General
20 NameEmpl No. BranchDeptRShipEligibilityUsageBalance Amount Rita87600KLACPrincipal Md. Idris17821JohorADPrincipal Kadir62145PenangHRPrincipal Tan Foo31361KLADPrincipal Siti1234KLACPrincipal Ravi4567PJHRPrincipal Afandi3456JohorGNChild Usage Vs Eligibility Report for the period of April2004 – June2004 Sample Report AC- Accounts HR- Human Resource GN-General
21 DiagnosisDepartmentTotal ACGNHRNo.Percentage Fever/Cough/Cold % Back Ache/Body Ache/ Joint Ache % Diarrohea/Vomiting/Food Poisoning % Diabetes Mellitus % Vertigo / Migraine % Gastrisitis % Most Active Treatment for the period April04 – June04 Quarterly Report Sample Report AC- Accounts GN- General HR- Human Resource
23 Amount (RM) Month Most Active Clinics Sample Report
24 Sample Report
25 OUTPATIENT PROCEDURES AND FLOWCHART
26 RAKYAT OUTPATIENT CLAIMS PROCEDURE For PANEL CLINIC Patient visits Rakyat Panel Clinic and produces Rakyat Health Card. Nurses have to make sure that the patient brings his/her own Rakyat card and IC. However, Dependants have to bring their parents IC and Rakyat card. The Rakyat GP Claim Form to be filled in full by the Patient, Nurse and the Doctor. Patient proceeds to seek consultation / treatment Patient proceeds to the Dispensing / Billing counter for Medication. ( No Payment to be made by the patient). Patients details and Medication Details to be entered in the Software provided by PCS Rakyat. GP Claim Forms fully filled to be sent to Rakyat Ofiice for Verification/Validation and Reimbursement..
27 RAKYAT OUTPATIENT CLAIMS PROCEDURE For PANEL CLINIC Patient Forgets Rakyat Card Process Flow If the patient forgets to bring Rakyat Card in case of Emergency / Accident / Lost Card. Contact our Call Centre : Hotline : 03 – (24 Hours) H/P:
28 RAKYAT OUTPATIENT CLAIMS PROCEDURE For NON PANEL CLINIC In case of Emergency patient visits a Non-Panel Clinic. Patient seeks Consultation / Treatment Patient proceeds to the Dispensing/Billing counter for Medication and Pays the Bill. Patient handover the Bill to the concerned Department (HR) of the Employer within 7 days.. Employer after verification send the Bill to Rakyat Office for payment within 14 days. Rakyat after Verification reimburse the payment to the Employee within 30 Days.
29 Panel Clinics in Malaysia Total Panel Clinics in Malaysia : Tawau Kudat Miri Semporna Pulau Sipadan Labuan Sarikei Bandar Sri Aman 1 4
30 SAMPLE RAKYAT OUT PATIENT CARD
32 P.C.S. Rakyat is well equipped with all the latest Computers, Printers and Scanners Personal Computers – Pentium IV – All PCs are interconnected via Local Area Netwrok (LAN) and 24 Hours connected to Internet. 2.4 Printers - Colour 3.HP Scanner Software System : P.C.S.Rakyat is having a Claim Management System - A Software developed by J.D.Systems to monitor all the Claims and Monthly Reports. The Software is also installed at the major Rakyat GP Panel Clinics to get the data online thru Internet and is working very well.
33 CLINICS PROPOSED DATA FLOW-DATA PROCESSING CLINICS A. Data transfer from Clinics: either by: ~Internet ~Diskettes B. Optional ~from PCS to clinics via Internet. P.C.S RAKYAT / CONTROL CENTRE P.C.S RAKYAT / CONTROL CENTRE ABC Berhad Server Offline Reports Monitoring Purpose only RakyatGroup Server
35 MAJOR ACCCOUNTS UNDER RAKYAT PLAN FOR OUTPATIENT (GP) – 1.INTEGRATED LOGISTICS BERHAD 2.SURIA BUSINESS SOLUTIONS (Subsidiary of Scomi Berhad) 3.PICSEL TECHNOLOGIES MALAYSIA (UK Based) 4.KOPERASI PERDANAJAYA SDN BHD 5.TRONOH CONSOLIDATED BERHAD 6.ZELAN CONSTRUCTION SDN BHD 7.ZELAN HOLDINGS (M) SDN BHD 8.ZELAN ENTERPRISES SDN BHD 9.ZELAN CORPORATION SDN BHD 10.ZELAN DEVELOPMENT SDN BHD 11.PANDUAN PELANGI SDN BHD 12.EUROPEAN PROFILES (M) SDN BHD 13.MALAYSIAN BAR COUNCIL 14.INFRASOFT TECHNOLOGIES LTD. 15.KOLEJ SAINS KESIHATAN BERSEKUTU 16.GAYA BINA CONTRUCTION SDN BHD 17.SILVER RIDGE HOLDINGS BERHAD 18.WOODLANDOR HOLDINGS BERAHD 19.SPECIFIC RESOURCES SDN BHD 20.JVC MANUFACTURING MALAYSIA 21.MISC INTEGRATED LOGISITICS SDN BHD 22.EDARAN OTOMOBIL NASIONAL BERHAD (EON) 23.EPE SWITCHGEAR SDN BHD
38 WELLNESS PROGRAM 1.Free Health & Wellness talks for Employees and their Dependants (Twice in a year) 2.Medical Advice (2 nd Opinion) 3.Legal Assistance on Medical Matters All the above services will be Free of Cost
40 IN-Patient Admission / Hospitalisation CLAIMS PROCEDURE for Panel Hospital Patient visits Hospital along with the reference letter from the Rakyat Panel GP Clinic and produce the In-Patient Card (issued by the Insurance Company) Patient needs to Fill the Hospital Admission Form. The Hospital will fax the form to the Insurance Company for Verification and Eligibility of the patient. A Guarantee Letter is forwarded to the Hospital from the Insurance Company within 30 mins (approx.) and the patient is admitted for the treatment if found eligible. Delay may be caused in getting Guarantee letter in few cases, but need to have patience. (Terms and Conditions apply). A Pre Discharge Billing Assessment is done to identify the Payable claims by the Patient and the Insurance Company. The Bill is forwarded to the Insurance Company for the final settlement/payment. The patient is discharged.
41 SAMPLE IN PATIENT CARD Note : The Hotline Number Managed by Asia Assistance Network (M) Sdn Bhd. (24 Hours) P.C.S.RAKYAT HOTLINE NUMBER : 03 – (24 HOURS)
45 WHY YOU SHOULD CHOOSE P.C.S.RAKYAT ?
46 Contact Us Office : 79 M, Jalan SS 21/1A, Damansara Utama Petaling Jaya, Selangor Tel: , 03 – Fax: Web : Contact Person: Executive Manager Asst. Manager Finance & Customer Service General