A METHOD OF EFFECTING A PAYMENT TO A SERVICE PROVIDER
ON BEHALF OF A MEMBER OF A MEDICAL SCHEME
BACKGROUND OF THE INVENTION
This invention relates to a method of effecting a payment to a service
provider on behalf of a member of a medical scheme and a system
therefor.
A traditional medical scheme operates where the provider of the medical
scheme undertakes liability in return for a premium or contribution and
provides to members who pay such premiums or make such contributions,
relevant health services and or assistance in defraying expenses incurred
in connection with rendering such relevant health services.
Typically, the amount of expenses the scheme will incur on behalf of the
member is preset and if the amount is exceeded, the member will be
required to fund the expense. In such cases, there is often an
inconvenience to the member to arrange payment and an inconvenience to
the service provider who will typically have to wait longer to obtain
payment
The invention provides a method of effecting a payment to a service
provider on behalf of a member of a medical scheme and a system
therefor.
SUMMARY OF THE INVENTION
According to an example embodiment there is provided a method of
effecting a payment to a service provider on behalf of a member of a
medical scheme:
receiving a request from a service provider for payment in respect of
services provided to a member of the medical insurance scheme;
determining if payments made to service providers on behalf of the
member exceed a predetermined amount within a predetermined
period;
if payments made exceed the predetermined amount, requesting a
payment from a credit facility of the member; and
if a payment from the credit facility of the member is approved then
effecting payment to the service provider.
In one embodiment, payment is effected by transferring data to a financial
institution, the data including at least data identifying the member, the
service provider and an amount to be paid to the service provider.
In another embodiment the level of the member in an incentive scheme is
used to calculate a discount which the member will receive when using the
credit facility to effect purchases.
In another embodiment an electronic system for effecting a payment to a
service provider on behalf of a member of a medical scheme includes:
a memory for storing:
information relating to payments made to service providers
on behalf of a member in a predetermined period; and
information relating to a predetermined amount payable; and
a processor disposed in communication with the memory, the
processor being adapted to:
receive a request from a service provider for payment in
respect of services provided to a member of the medical
insurance scheme;
determining if payments made to service providers on behalf
of the member exceed the predetermined amount within a
predetermined period;
if payments made exceed the predetermined amount,
requesting a payment from a credit facility of the member;
and
if a payment from the credit facility of the member is
approved then effecting payment to the service provider.
The processor may further be adapted to effect payment by transferring
data to a financial institution, the data including at least data identifying the
member, the service provider and an amount to be paid to the service
provider.
The processor may also further be adapted to use the level of the member
in an incentive scheme to calculate a discount which the member will
receive when using the credit facility to effect purchases.
BRIEF DESCRIPTION OF THE DRAWINGS
Figure 1 is a flow chart illustrating the methodology of the present
invention; and
Figure 2 is a flow chart illustrating how different systems
communicate with one another to implement the present
invention.
DESCRIPTION OF A PREFERRED EMBODIMENT
Referring to Figure 1, a provider of a medical scheme receives a request
from a service provider for payment in respect of services provided to a
member of the medical insurance scheme.
The received request is in the form of a claim from the provider. The claim
is translated and adjudicated by the systems of the medical scheme
meaning that the data from the claim is extracted, the nature of the claim
identified and a decision is taken as to whether the claim is valid and the
service provider should be paid.
Once the payment is authorised, a decision needs to be taken if payments
previously made to service providers on behalf of the member exceed a
predetermined amount within a predetermined period.
This is because the medical scheme typically insures the member up to a
certain predetermined amount and if the amount is exceeded, the member
will be required to fund the service providers themselves. For example, a
member may have a limit of R1,000 for medication for a calendar year.
Once the medical scheme has paid R1,000 for medication on the members
behalf the medical scheme will not pay for any further medication during the
calendar year.
In such circumstances, a service provider submitting a claim for payment
for medication issued to the member will have the claim refused by the
medical scheme and will need to revert to the member for payment.
This is inconvenient for both the service provider who will have a delay in
receiving payment and for the member who now needs to arrange
separately for payment.
According to the present invention, if payments made to service providers
on behalf of the member exceed a predetermined amount within a
predetermined period a request for payment is automatically generated and
transmitted to a credit facility for the payment
The credit facility is typically in the form of a credit card facility of the
member that the member has with a financial institution.
If payment from the credit facility of the member is approved then payment
to the service provider will be effected.
The member will obviously be billed in the normal manner by the financial
institution.
Although the member is required to authorise the use of the credit facility,
the member will not be required to authorise the use of the credit "facility for
a particular transaction.
Obviously, in order to implement the above-mentioned scheme systems
need to be implemented between 1he medical scheme and the external
financial institution.
In some jurisdictions legislation prevents medical schemes 1rom extending
credit to its members. As such, the present invention may need to be
implemented in conjunction with a financial institution such as a bank.
It will be appreciated that in this scenario the systems of the medical
scheme need to communicate with the systems of the financial institution.
Figure 2 illustrates an exemplary methodology of the communicating
systems.
Once a member agrees to the credit facility, a credit account referred to as
an Medical Budget Facility (MBF) is opened by the financial institution. The
system of the financial institution extracts all available balances and
transfers these to the credit card system of the medical scheme.
If a payment is required to be made from the credit facility, the medical
scheme system checks to see if funds are available. If funds are not
available, the request is declined and the claim rejected.
If the funds are available, funds are allocated for the particular claim in the
medical scheme system and information is communicated to the financial
institution to allow the claim to be processed.
The information to process the claim will obviously need to include an
identification of the member, an identification of the third party to whom the
amount is to be paid and the amount to be paid.
The financial institution continually updates the available balances by
transmitting this information to the system of the medical scheme.
An electronic system to implement the invention includes a memory for
storing information relating to payments made to service providers on
behalf of a member in a predetermined period and information relating to a
predetermined amount payable.
The system also includes a processor disposed in communication with the
memory, the processor being adapted to receive a request from a service
provider for payment in respect of services provided to a member of the
medical insurance scheme.
The processor is further adapted to determine if payments made to service
providers on behalf of the member exceed the predetermined amount
within a predetermined period and if so to request a payment from a credit
facility of the member. If a payment from the credit facility of the member is
approved then effecting payment to the service provider.
Where the credit facility is in the form of a credit card, for example,
members of the medical scheme can be motivated to look after their health
by awarding them discounts on purchases made using the credit card.
In this regard, South African patents numbers 99/1746 and 2001/3936, the
contents of which are incorporated herein by reference, describe a method
of managing a medical insurance plan wherein a plurality of health-related
facilities and or services are offered to members of the medical insurance
plan. The patents list a number of health-related facilities and/or services,
examples of which are an approved health club or gymnasium, a weightloss
programme or a smoke ender programme. Use of the facilities and/or
services by members is monitored and points are awarded to a member for
using the facilities and/or services. The following table summarises
examples of points-earning activities:
(Table Removed)Further, as described in these patents, a plurality of status levels in an
incentive scheme are defined which are described in these patents as blue,
bronze, silver and gold. Depending on the number of points a member is
awarded, one of these status levels are allocated to the member so that the
member's status level is essentially according to the use of the facilities and
or services.
Finally, a reward is allocated to the members depending on their status
level.
According to the present invention, the reward will be a predetermined
discount when using the credit card to make purchases, wherein the
discount it typically in the form of a percentage and the percentage
increases as depending on the member's status level.
For example, a gold member may be awarded a 10% discount; a silver
member a 7% discount, a bronze member a 5% discount and a blue
member a 2% discount.
In one embodiment the discounts apply only when purchases are made at
certain participating shops while in another embodiment the discount will
apply irrespective of the shop.
Certain participating shops may give more or less discounts than other
participating shops.
11
Thus it will be appreciated that the healthier a member is the more they will
save on purchases made using the credit facility.

CLAIMS:
1. A method of effecting a payment to a service provider on behalf of a
member of a medical scheme, the method including:
receiving a request from a service provider for payment in
respect of services provided to a member of the medical
insurance scheme;
determining if payments made to service providers on behalf
of the member exceed a predetermined amount within a
predetermined period;
if payments made exceed the predetermined amount,
requesting a payment from a credit facility of the member;
and
if a payment from the credit facility of the member is
approved then effecting payment to the service provider.
2. A method according to claim 1 wherein payment is effected by
transferring data to a financial institution, the data including at least
data identifying the member, the service provider and an amount to
be paid to the service provider.
3. A method according to claim 1 or claim 2 wherein the level of the
member in an incentive scheme is used to calculate a discount
which the member will receive when using the credit facility to effect
purchases.
4. An electronic system for effecting a payment to a service provider
on behalf of.a-member .of-a medical-scheme, the^system including:
a memory for storing:
information relating to payments made to service
providers on behalf of a member in a predetermined
period; and
information relating to a predetermined amount
payable; and
a processor disposed in communication with the memory, the
processor being adapted to:
receive a request from a service provider for payment
in respect of services provided to a member of the
medical insurance scheme;
determining if payments made to service providers
on behalf of the member exceed the predetermined
amount within a predetermined period;
if payments made exceed the predetermined amount,
requesting a payment from a credit facility of the
member; and
if a payment from the credit facility of the member is
approved then effecting payment to the service
provider.
5. An electronic system according to claim 4 wherein the processor is
further adapted to effect payment by transferring data to a financial
institution, the data including at least data identifying the member,
the service provider and an amount to be paid to the service
provider.
6. An electronic system according to claim 4 wherein the processor is
further adapted to use the level of the member in an incentive
scheme to calculate a discount which the member will receive when
using the credit facility to effect purchases.