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Pharmaceutical Benefit Management
Qualsa has developed a state-of-the-art Qualsa Pharmaceutical Benefit Management (QPBM) solution, which surpasses the current pharmaceutical benefit management facilities available in the healthcare market.
QPBM sets the standard for online administration of medication claims in South Africa, allowing medical schemes to transact online with providers throughout South Africa and to administer benefits that are customised to their requirements in a highly automated environment. The system is supported by call centres to assist clients, members and service providers with administrative, clinical and technical queries.
Across the medical aid industry, medication expenditure accounts for a significant proportion of total benefit expenditure with the latest (2008 - 2009) report from the Council for Medical Schemes (CMS) indicating the average figure to be at 17.3%. It is essential for the medical schemes to have adequate control over the utilisation of medication by reducing medication costs, improving clinical outcomes and transacting electronically in real time. QPBM is designed to give a medical scheme full control of this process through a seamless and integrated offering.
The Qualsa solution is distinctly different from the other offerings in the healthcare market for a number of reasons:
- Seamless integration enabling a single view of the patient.
- Clinical expertise supporting the development and maintenance of the product.
- Clinical rules-based systems for chronic, acute, self (over-the-counter) and other medication benefit management.
- Acute to chronic conversion which is an innovative QPBM tool that identifies patients or members who are claiming possible chronic medication from their acute medication benefit. This tool informs the member and advises them (as well as their treating doctor) to apply for authorisation of that medication from the chronic medication benefit. This allows proper usage of the various medication benefits in the members' best interest.
- Integrated Formulary management.
- Qualsa's Preferred Pharmacy Network (PPN).
- Designated Service Provider Pharmacy Network.
- Constant systems innovation.
- Reference pricing including industry-leading Therapeutic Reference Pricing product.
- Integrated fraud risk strategy.
For more information, visit the Qualsa Pharmaceutical Benefit Management site.
Should you prefer to contact QPBM directly:
Telephone Number: 021 480 4485
Fax: 021 480 6861
E-mail: pbmqueries@mhg.co.za