Hospital Risk Management

The reality of the ever-increasing expenditure on hospitalisation costs for medical schemes, accompanied by concerns about the future affordability and accessibility of hospital care to scheme members, makes our Hospital Risk Management (HRM) programme a prerequisite for all medical schemes.


This programme is dedicated to the management of Major Medical Benefits and encompasses all medical and surgical admissions to hospital, admissions to alternatives to hospital, utilisation of specialised radiology, the use of prostheses, the use of appliances and surgical procedures. The programme is customised according to the requirements of each scheme taking into consideration their benefit design and scheme rules.


Our programme offers: 

  • Standard operating procedures, protocols and formularies to ensure that appropriate and cost-effective treatment is rendered to members in a measurable and consistent manner.
  • Pre-authorisation and Intensive case management of high-risk and high-cost admissions.
  • Discharge and step-down planning and management service.
  • Real-time management of accompanying chronic conditions and diseases which are flagged at the time of the authorisation.
  • Clinical audit and retrospective review of hospital claims.
  • Fee negotiations with hospitals on behalf of the scheme.
  • Investigation of alternative reimbursement mechanisms for consideration by the scheme.
  • Ongoing input into annual benefit design to ensure appropriate behaviour and sufficient cover.

Unique HRM features


Patient profile screen
The patient profile screen offers a ‘one-stop' view of all the information available on the patient and ensures that the case managers have up-to-date information on a member's profile and risk factors.


Ability to interface directly with hospitals
Metropolitan Health Risk Management links directly with hospital groups via a business-to-business process to create a seamless interface for hospitalisation authorisation. This interface allows the hospital to request an authorisation or an update of an existing authorisation in real time.


Close integration with our Disease Risk Management programmes
Our Disease Risk Management programmes, such as HIV/AIDS, Diabetes and Hypertension, are specially constructed to integrate with the Hospital Risk Management component of Metropolitan Health Risk Management's offering, thus reinforcing the holistic view of the patient and creating potential for further cost efficiencies.


Key components of the most prevalent HRM operating model

The programme is delivered via a call centre model where a member or provider can make contact with HRM via telephone, fax, e-mail and business-to-business to request authorisation for an event. There is a minimum data requirement before HRM will issue an authorisation to manage the scheme's risk and to ensure appropriate utilisation of medical scheme resources.

All authorisations are captured in QUI (Qualsa User Interface), an in-house interface that is customised by user, scheme and workflow processes in each business unit. There are three main functional areas that comprise HRM product delivery, namely:

  • Pre-authorisation - this area is responsible for data capturing and some processing of authorisation requests as they arrive in the HRM environment. At this stage of the process an authorisation can already be issued if deemed to be clinically appropriate and simple requests would be fully managed at this level. The caller is sent written correspondence with a unique QHA number (Qualsa Hospital Authorisation number) confirming the authorisation. Parallel correspondence is also sent to the admitting facility as well as the attending physician.
  • Case management - this area has been sub-divided into several clusters to ensure streamlined service delivery.

The first area is HRM case managers who handle the more complex authorisation requests.


The second area is Concurrent Reviewers and these case managers deal with clinical updates from the various hospitals on existing authorisations. They pro-actively seek out cases that have exceeded authorised length of stay (LOS) and where the level of care (LOC) has changed. These cases are defined in QUI.


The third area is Intensive Case Management. The specific focus of this area is ICU, high care and prolonged admissions. The team manage cases where it is clinically appropriate to move them into a lower level of care by negotiating with the attending physician and facilities.


Hospital Retrospective Review Programme (HRP) - this is the claims adjudication function that scrutinises hospital claims to manage over coding and inappropriate billing.


All case managers in the business unit have access to a full-time medical advisor who is on hand to assist with complex clinical queries and engage with clinicians when the need arises.