2 Company BackgroundPioneer & time proven Managed Care Organisation (MCO) in MalaysiaThird Party Administrator (TPA)Established on 15th Nov’2001Specialist- dedicated core business activity (not a side business)Managed by insurance experts and supported by full time medical doctors
3 Company’s Goal To be Malaysia’s 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 P.C.S. RAKYAT SDN BHD BOARD OF DIRECTORS Abdul Aziz Nor Chairman (LLB Hons Essex University, London)ChairmanS.GopinathGroup Executive DirectorDr. Madhavan NairDirector MedicalDr. Avtar SinghDirector Medical (Penang)
7 Our Responsibilities, Your Advantages P.C.S. RAKYAT SDN BHDOur Responsibilities, Your AdvantagesWe :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 ProgramSave your valuable Time and Headaches.
8 Functions & Operations 24- hour helpdesk lineRoadshow for issuance of cardsAppoint and select panel clinicsAdministrating claimsMonitoring claimsGenerating management reports based on clinic claimsReview of Clinic Bills
9 How the cost will be reduced ? Review of Medical BillsMonitoring of Clinic BillsQuerying the Clinics/DoctorsSupplying the medicines for Long term Illness.Wellness ProgramMonitoring the frequent visits report.Reduce the hidden cost of the client.
13 Managed Care Flow Chart for Outpatients EMPLOYEESABC BERHADOutpatient BenefitsMonthly PaymentPresent Rakyat OP card and get treatmentSubmit ReportsManaged by P.C.S.Rakyat Sdn BhdPanel Clinics/ SpecialistSubmit Claim Forms & BillsPay Clinic Bills
14 Specialist Visit (referred by Panel Clinic) P.C.S. RAKYAT OUT-PATIENT SCHEMEOUTPATIENT CARE BENEFITSPlan IndividualPlan FamilyPlan Single ParentGP Clinic Service for Outpatient Consultation includingCoveredNILCovered Child : up to 21 yrs oldDrugsBasic Diagnostic tests including Lab Tests/X-Ray/ECGChildhood ImmunisationsURGENT/EMERGENCY CARENationwide Emergency Health CoverageCovered hoursProvided by GP or Specialist on an Outpatient BasisAccording to Benefits LimitSpecialist Visit (referred by Panel Clinic)Specialist Care & Diagnostic ServicesCovered in FullCovered in FullCovered in FullSpecialist Consultations, Diagnostics Procedures & Recommended Drugs via Specialist Consultant
15 OUT PATIENT SCHEME P.C.S. RAKYAT SDN BHD EXCLUSION CLAUSESThe exclusion of the Rakyat Out Patient Programme are as follows:Pregnancy and abortionFamily planning services, sterilization procedures and work-up or treatment of infertilityTreatment, examination and lab tests not ordered by Medical PractitionerTraditional and alternatives therapy such as Acupuncture, Homeopathy, Bomoh or Sinseh TreatmentInjuries due to insanity or self-inflictedAIDS (Acquired Immune Deficiency Syndrome) & HIV related DiseasesTravel & Adult immunization including HepatitisDirect sales nutritional productsTreatment to improve the psychological, mental or emotional well-being
16 Any changes can be discussed P.C.S. RAKYAT SDN BHDEXCLUSION CLAUSESCosmetic Surgery for purpose of beautification or plastic surgery including sex change surgeryDietary supplements, appetite, suppressants, anabolic steroids and cosmetics productsExpenses which should be claim under SOCSO / Workmen’s Compensation SchemeMedical examination, required by third party such as Pre-employment examination, Vehicle licensing examination & regular screening profilesTelephone, fax charges, private nursing, lodger fee, administrative registration fee & nonmedical personal itemsTreatment 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 epidemicSonotron 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
18 Monthly Clinic Claim Report-April’2004 Sample ReportP.C.S. RAKYAT SDN BHDMonthly Clinic Claim Report-April’2004Date of VisitNameEmpl No.BranchDeptR’ShipClinicDoctorDiagnosisMC daysCharges01/04/04C.Sivarajan12048P.KlangHRPrincipalKlinik RaviDr. AzharFever/Cough/Cold230.0002/04/04Hamidon Buang65032JohorADNorhayatiSpouseKlinik DeepaDr. UshaTonsilitis40.0003/04/04Sulaiman Bin Alimon76800PenangKlinik FamiliDr. JoeDiarrhoea135.0005/04/04Tong Fei Loong80963KLGNKlinik PublicDr. ChuahRashes45.00Rita87600ACKlinik AmarDr. AmarEye Infection55.00Mohd Idris17821Klinik Nik IsaDr. AisahMigraine65.00Abd Kadir62145MedivironDr. TanBronchitis10/04/04Md Elai Bin Fadzil23456Klinik SegaraDr. SasiBack Ache/Body AcheHR- Human ResourceAD - AdministrationGN- GeneralTOTAL
19 Monthly Employee Claim Report-April’2004 Sample ReportP.C.S. RAKYAT SDN BHDMonthly Employee Claim Report-April’2004Date of VisitNameEmpl No.BranchDeptR’ShipClinicDoctorDiagnosisMC daysCharges01/04/04C.Sivarajan12048P.KlangHRPrincipalKlinik RaviDr. AzharFever/Cough/Cold230.0002/04/04Fever08/04/04Klinik FamiliDr. JoeDiarrhoea135.0012/04/04Klinik PublicDr. ChuahRashes45.00Klinik AmarDr. AmarEye Infection55.00Klinik Nik IsaDr. AisahMigraine65.00MedivironDr. TanBronchitisHR- Human ResourceAD - AdministrationGN- GeneralTOTAL
20 Usage Vs Eligibility Report for the period P.C.S. RAKYAT SDN BHDSample ReportUsage Vs Eligibility Report for the periodof April’2004 – June’2004NameEmpl No.BranchDeptR’ShipEligibilityUsageBalanceAmountRita87600KLACPrincipal300.00Md. Idris17821JohorAD600.00900.00Kadir62145PenangHRTan Foo31361800.00700.00Siti1234Ravi4567PJAfandi3456GNChildAC- AccountsHR- Human ResourceGN-General
21 Most Active Treatment for the period April’04 – June’04 Sample ReportP.C.S. RAKYAT SDN BHDMost Active Treatment for the period April’04 – June’04Quarterly ReportDiagnosisDepartmentTotalACGNHRNo.PercentageFever/Cough/Cold2518327540 %Back Ache/Body Ache/ Joint Ache15103518 %Diarrohea/Vomiting/Food Poisoning08062413 %Diabetes Mellitus07041910 %Vertigo / Migraine059.6 %Gastrisitis03168.5 %AC- AccountsGN- GeneralHR- Human Resource
26 RAKYAT OUTPATIENT CLAIMS PROCEDURE For PANEL CLINICPatient 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 / treatmentPatient proceeds to the Dispensing / Billing counter for Medication. ( No Payment to be made by the patient).Patient’s 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 CLINICPatient Forgets Rakyat CardProcess FlowIf 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 In case of Emergency patient visits a Non-Panel Clinic. RAKYAT OUTPATIENT CLAIMS PROCEDUREFor NON PANEL CLINICIn case of Emergency patient visits a Non-Panel Clinic.Patient seeks Consultation / TreatmentPatient 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 P.C.S. RAKYAT SDN BHDPanel Clinics in Malaysia45Kudat1010652201Labuan90Semporna Pulau Sipadan903003TawauMiri2012153203Sarikei6022Bandar Sri Aman5001Total Panel Clinics in Malaysia : 1400
30 SAMPLE RAKYAT OUT PATIENT CARD P.C.S. RAKYAT SDN BHDSAMPLE RAKYAT OUT PATIENT CARD
31 EQUIPMENTS/TOOLS/SYSTEMS P.C.S. RAKYAT SDN BHDEQUIPMENTS/TOOLS/SYSTEMS
32 P.C.S. RAKYAT SDN BHD Software System : P.C.S. Rakyat is well equipped with all the latest Computers, Printers and Scanners.10 Personal Computers – Pentium IV – All PC’s are interconnected via Local Area Netwrok (LAN) and 24 Hours connected to Internet.4 Printers - ColourHP ScannerSoftware 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 A. Data transfer from Clinics: either by: ~Internet ~Diskettes PROPOSED DATA FLOW-DATA PROCESSINGCLINICSA. Data transferfrom Clinics:either by:~Internet~DiskettesB Optional~from PCS toclinics viaInternet.P.C.S RAKYAT / CONTROLCENTREABC BerhadServerOffline ReportsMonitoringPurpose onlyRakyatGroupCLINICSCLINICSCLINICS
35 P.C.S. RAKYAT SDN BHDMAJOR ACCCOUNTS UNDER RAKYAT PLAN FOR OUTPATIENT (GP) –INTEGRATED LOGISTICS BERHADSURIA BUSINESS SOLUTIONS (Subsidiary of Scomi Berhad)PICSEL TECHNOLOGIES MALAYSIA (UK Based)KOPERASI PERDANAJAYA SDN BHDTRONOH CONSOLIDATED BERHADZELAN CONSTRUCTION SDN BHDZELAN HOLDINGS (M) SDN BHDZELAN ENTERPRISES SDN BHDZELAN CORPORATION SDN BHDZELAN DEVELOPMENT SDN BHDPANDUAN PELANGI SDN BHDEUROPEAN PROFILES (M) SDN BHDMALAYSIAN BAR COUNCILINFRASOFT TECHNOLOGIES LTD.KOLEJ SAINS KESIHATAN BERSEKUTUGAYA BINA CONTRUCTION SDN BHDSILVER RIDGE HOLDINGS BERHADWOODLANDOR HOLDINGS BERAHDSPECIFIC RESOURCES SDN BHDJVC MANUFACTURING MALAYSIAMISC INTEGRATED LOGISITICS SDN BHDEDARAN OTOMOBIL NASIONAL BERHAD (EON)EPE SWITCHGEAR SDN BHD
36 OTHER CLASSES OF INSURANCE CLIENTS P.C.S. RAKYAT SDN BHDOTHER CLASSES OF INSURANCE CLIENTS
38 All the above services will be Free of Cost P.C.S. RAKYAT SDN BHDWELLNESS PROGRAMFree Health & Wellness talks for Employees and their Dependants (Twice in a year)2. Medical Advice (2nd Opinion)3. Legal Assistance on Medical MattersAll 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 P.C.S. RAKYAT SDN BHD 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 P.C.S. RAKYAT SDN BHDWHY YOU SHOULD CHOOSE P.C.S.RAKYAT ?
46 Contact Us Office : 79 M, Jalan SS 21/1A, Damansara Utama 47400 Petaling Jaya,SelangorTel: , 03 –Fax:Web :Contact Person:Chairman :Executive Director :Manager Operations :Asst. Manager Finance & Admin :Customer Service ;General Enquiries :