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GEMS pays out 91m claims amounting to R29.1bn in 2017

The Government Employees Medical Scheme (GEMS) paid out 91m claims for its 1.8m-strong membership base during 2017, amounting to a total value of more than R29.1bn.

According to Dr Guni Goolab, principal officer of GEMS, the claims included 5.6m family practitioner consultations, 440,738 hospital admissions and close on a million medical specialist consultations. There were 24,538 babies delivered, 87,348 specialist consultations for pregnancy supervision, 13,162 cataract procedures, and over 45m medicines among the 91m claim lines covered.

“Not only did the scheme pay claims exceeding R29bn, which represents a significant amount of healthcare expenditure, but we have also worked hard to make sure these funds stretch further through the validation of claims and agreements with our network of healthcare providers,” Goolab said.

Placing an emphasis on the role of primary healthcare and preventative care, and the introduction of measures such as care coordination has allowed the scheme to take good care of members’ day-to-day health needs while ensuring benefits are available should they require hospitalisation or specialists’ services.

“We have also worked hard to develop a closer relationship with our members and empower them with knowledge about the benefits they are entitled to, how to submit claims correctly and what they need to do to ensure they get maximum value out of their GEMS membership,” Goolab said.

During 2017, the 18 GEMS Walk-In Centres had 634,097 face-to-face consultations with members and prospective members. The GEMS Call Centre recorded some 3.5m telephone calls, while GEMS corresponded with members via 22.7m short message service (SMS) messages.

“By the end of 2017, our Client Liaison Office (CLO) Unit was fully operational in Gauteng, KwaZulu-Natal, Eastern Cape, Free State, Limpopo and Mpumalanga, reaching 4,370 new sites. CLOs visit members in the workplace, providing convenient face-to-face service in the member’s preferred language. A total of 290,091 enquiries were received for investigation and finalisation, with an average on-site resolution rate of 88% across all regions,” Goolab said.

The CLO Unit hosted member education sessions and focus group meetings to engage members about their understanding, expectations and experience of the scheme. Furthermore, GEMS Days held in partnerships with government departments and labour unions brought face-to-face GEMS services to approximately 4 600 members in Eastern Cape, Limpopo, Mpumalanga and Gauteng during 2017.

In addition, roadshows held in all nine provinces provided an opportunity for some 4,000 members to share their insights and engage with the scheme. Some 900 human resources practitioners engaged with the scheme during stakeholder engagements.

“These opportunities for two-way communication have been extremely helpful, and allowed the scheme to reach out more proactively to empower our members with the information they need to make healthy lifestyle choices and maximise their benefits.”

In October 2017 the scheme launched the GEMS member App and portal, bringing a new level of convenience to members and their dependents. “Harnessing the power of digital technology not only empowers our members to understand their benefits and our services better, it also allows GEMS and our service providers to work smarter and more efficiently to enhance service and, ultimately, the member experience,” Goolab says.

This innovation means that members are now able to submit claims, update their personal information and submit hospital authorisation requests themselves, thereby reducing the need for members to complete paperwork or contact the GEMS call centre.

“For GEMS and relevant service providers, this enhanced efficiency means we have a greater capacity to focus on other aspects of improving the GEMS experience for our valued members. As GEMS, we are now focusing on ways of enhancing the member experience at every opportunity,” Goolab said.

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