SUNConferences, Computers and Industrial Engineering 42

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Development Of A Tariff Tool For Medical Aids Within Africa
Dieter Hartmann, Tom M Morrison, Charles Harebottle

Last modified: 2012-06-25

Abstract


A medical risk management company provides medical claim assessment and payment for large medical insurers within Africa. The industry currently lacks cost and payment benchmarks, leading to abuse and significant continent-wide variation.

A database of paid claims, covering 18 African countries with 3128 medical providers, was mined and statistically analysed. This paper presents a model which was developed to provide a basic tariff and pricing structure for monitoring and capturing claims.

The model provides an appropriate-cost-threshold based on tolerable probability settings. This was partially achieved by inflation and exchange rate normalisation (including purchasing power parity). The model estimates and evaluates cost based on the country of treatment, medical condition and benefit option selected. It further provides decision support for appropriate currency of reimbursement. A preferential provider (Key accounts) list was developed using the model, to facilitate tariff and price negotiation.

The model was tested on third party data and significant initial savings were identified.


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