Healthcare Funders And Administrators

MediKredit’s PBM services have become synonymous with providing medical schemes with access to appropriate, cost-effective medicines for over 80 years.

MediKredit’s electronic health benefit management (HeBM®) has its own switching capabilities and uniquely patented claims adjudication system with the expertise to customise the gate keeping claims adjudication services to the particular requirements of each of our healthcare funder clients, including medical schemes.

MediKredit prides itself in the development and maintenance of evidence-based protocols, drug utilisation reviews (DUR) for chronic and high-cost medicines and an efficient pre-authorisation process.

Through our online real-time system, MediKredit manages Pharmacy Advised Therapy (PAT) and acute medicine utilisation at point of sale.

We assist in managing our client medicine expenditure end-to-end by providing sophisticated, detailed reporting, ensuring a holistic view of the beneficiary’s healthcare benefit spend.

Our offering includes:

  • Online real-time medicine claims processing
  • Drug utilisation review (DUR)
    • Development and maintenance of evidence-based protocols, formularies, and condition medicine lists
    • Monitoring and evaluation of the effectiveness of cost, quality, and access to medicine and healthcare services for beneficiaries
  • Telephonic pre-authorisation of chronic conditions (paperless)
    • Reducing beneficiary frustration
    • Assisting in maintaining doctor/patient relationship
  • Reporting
    • Management of end-to-end medicine expenditure
    • Ensuring a holistic view of the beneficiary’s healthcare benefit spend
  • Call centre services
    • Clinical, operational and provider call centre services
  • Pharmacy provider network (PPN) connectivity and management of negotiated dispensing fees
    • Ensuring optimal beneficiary access and experience
    • The network runs on a “willing pharmacy” principle
    • MediKredit is integrated with every pharmacy in South Africa and we are proud to have extended our services to doctors, hospitals and other healthcare providers
  • Real-time adjudication rules:
    • Financial risk management e.g., pricing, reference pricing, benefit limits, early refill
    • Healthcare funder benefit rules e.g., exclusions, DSP, networks
    • Clinical risk management e.g., formularies, pre-authorisation
    • Patient safety rules e.g., appropriate dosage, therapeutic duplication
    • Eligibility rules e.g., member, provider
    • Industry rules e.g., ICD-10, BHF, stale claims
    • Transaction validations e.g., mandatory fields, duplicates
    • Pharmacy Advised Therapy (PAT) and acute medicine utilisation at point of sale