Explain your pricing Price transparency in respect of List assumptions made the services provided i.e. Include assumptions made and how do you arrive at your rationale followed in building your price relevant to the pricing model. capitation or contracted Provide cost efficiency analysis and fee for the risk managed clearly indicate the sustainability of by your organisation. the capitation arrangement and cover revenue vs expenditure and done per healthcare discipline. Explain by way of cost efficiency analysis how your managed care /admin processes (output criteria) reduced the cost and maximised the clinical outcomes for client scheme’s members. Supply comparative data quarter to quarter over a 12 month period. From the fees received, Provide details and breakdown of what co-admin fees are items. payable to other parties Provide full details of re-insurance e.g. administrator, arrangements if any and indicate the etc nature and extent of the risk so Reimbursement Provide details of the E.g. negotiated fee, fee for service or mechanism(s) reimbursement capitation arrangements, etc. mechanism(s) used to Describe the reimbursement and reimburse healthcare process to arrive at the respective fee providers where services determination are outsourced. Clear indication that services are sustainable through reimbursement model and balanced with healthcare provision to beneficiaries Quality of Care How has the provision of Explain how quality is measured and this service by your monitored. Compare these indicators organisation(input criteria) to local and international standards impacted on the quality of quality of measure. care received by medical Demonstrate use of protocols and scheme members? illustrate focus on health outcomes rather than denial of benefits. Effect of interventions relative on e.g. % re-admissions during a particular period.
Explain your pricing in respect of the services provided i.e. how do you arrive at your price relevant to the capitation or contracted fee for the risk managed by your organisation. Price transparency List assumptions made Include assumptions made and rationale followed in building your pricing model. Provide cost efficiency analysis and clearly indicate the sustainability of the capitation arrangement and cover revenue vs expenditure and done per healthcare discipline. Explain by way of cost efficiency analysis how your managed care /admin processes (output criteria) reduced the cost and maximised the clinical outcomes for client scheme’s members. Supply comparative data quarter to quarter over a 12 month period. From the fees received, what co-admin fees are payable to other parties e.g. administrator, etc Provide details and breakdown of items. Provide full details of re-insurance arrangements if any and indicate the nature and extent of the risk so Reimbursement mechanism(s) Provide details of the reimbursement mechanism(s) used to reimburse healthcare providers where services are outsourced. E.g. negotiated fee, fee for service or capitation arrangements, etc. Describe the reimbursement and process to arrive at the respective fee determination Clear indication that services are sustainable through reimbursement model and balanced with healthcare provision to beneficiaries Quality of Care How has the provision of this service by your organisation(input criteria) impacted on the quality of care received by medical scheme members? Explain how quality is measured and monitored. Compare these indicators to local and international standards quality of measure. Demonstrate use of protocols and illustrate focus on health outcomes rather than denial of benefits. Effect of interventions relative on e.g. % re-admissions during a particular period.