Finance and Treasury

Medical Schemes and Health Insurance Administration

Health cover is administered under constant pressure from rising utilisation, a member population that changes shape as people join and leave, and providers whose billing is not always what it appears. This course covers running it. Delegates work through benefit design and the trade off between contribution and cover, including the options that attract exactly the members who cost most. Membership administration follows, covering enrolment, dependants, waiting periods and the exclusions that must be applied consistently. Provider networks, tariffs and contracting are addressed. Claims adjudication is covered, including coding, clinical rules and pre authorisation. Fraud, waste and abuse are treated directly, covering the billing patterns that indicate each. Utilisation review and managed care interventions follow. Reserving, contribution setting and the annual increase decision are addressed. Member communication and complaints are covered. The course closes on regulatory obligations and on sustaining a scheme as its membership ages.