SAQA All qualifications and part qualifications registered on the National Qualifications Framework are public property. Thus the only payment that can be made for them is for service and reproduction. It is illegal to sell this material for profit. If the material is reproduced or quoted, the South African Qualifications Authority (SAQA) should be acknowledged as the source.
SOUTH AFRICAN QUALIFICATIONS AUTHORITY 
REGISTERED UNIT STANDARD THAT HAS PASSED THE END DATE: 

Manage costs in a specific case with due regard for quality 
SAQA US ID UNIT STANDARD TITLE
242565  Manage costs in a specific case with due regard for quality 
ORIGINATOR
SGB Insurance and Investment 
PRIMARY OR DELEGATED QUALITY ASSURANCE FUNCTIONARY
-  
FIELD SUBFIELD
Field 03 - Business, Commerce and Management Studies Finance, Economics and Accounting 
ABET BAND UNIT STANDARD TYPE PRE-2009 NQF LEVEL NQF LEVEL CREDITS
Undefined  Regular  Level 5  Level TBA: Pre-2009 was L5  2 
REGISTRATION STATUS REGISTRATION START DATE REGISTRATION END DATE SAQA DECISION NUMBER
Passed the End Date -
Status was "Reregistered" 		 2018-07-01  2023-06-30  SAQA 06120/18 
LAST DATE FOR ENROLMENT LAST DATE FOR ACHIEVEMENT
2026-06-30   2029-06-30  

In all of the tables in this document, both the pre-2009 NQF Level and the NQF Level is shown. In the text (purpose statements, qualification rules, etc), any references to NQF Levels are to the pre-2009 levels unless specifically stated otherwise.  

This unit standard does not replace any other unit standard and is not replaced by any other unit standard. 

PURPOSE OF THE UNIT STANDARD 
This unit standard is intended for learners work with clinical and/or cost management in a medical scheme. It would be useful for Risk Managers, Case Managers, senior people in intervention or drug utilisation review (DUR) and a managed care environment.

The qualifying learner is capable of:
  • Applying technical knowledge and skill to determine whether a case is general or exceptional for a medical scheme.
  • Analysing the cost and quality of benefits in a general case.
  • Analysing the benefits of a medical procedure or treatment to a patient for an exceptional case.
  • Analysing the cost of benefits to a medical scheme of a specific procedure or treatment for an exceptional case.
  • Making a recommendation for a case under investigation. 
    		•

    LEARNING ASSUMED TO BE IN PLACE AND RECOGNITION OF PRIOR LEARNING 
    It is assumed that learners are competent in Communication and Mathematical Literacy at NQF Level 4. 

    UNIT STANDARD RANGE 
    The typical scope of this unit standard is:
  • Risk impact includes general and exceptional cases.
  • Conditions relating to the payment of a benefit include, but are not limited to, co payments, formularies, protocols, pre-authorisation and generic substitutes.
  • Rationale for a protocol or treatment includes, but is not limited to, compassionate use, increase in the quality of life of the patient or community care giver or people involved with the patient, treatment of the condition, positive outcome, initial high cost intervention with the prospect of saving money over the long term, sustainable quality of life (palliative care) new technology not yet available in South Africa. 
    		•

    Specific Outcomes and Assessment Criteria: 

    SPECIFIC OUTCOME 1 
    Apply technical knowledge and skill to determine whether a case is general or exceptional for a medical scheme. 

    ASSESSMENT CRITERIA     

    ASSESSMENT CRITERION 1 
    Knowledge of scheme rules and benefit options are applied to a specific case to determine whether the case is covered under the normal benefit structure of the medical scheme. 

    ASSESSMENT CRITERION 2 
    The risk impact of a specific case is analysed in terms of added cost to the medical scheme. 

    SPECIFIC OUTCOME 2 
    Analyse the cost and quality of benefits in a general case. 

    ASSESSMENT CRITERIA     

    ASSESSMENT CRITERION 1 
    The protocols and formulary relating to a specific condition are applied to a normal case. 

    ASSESSMENT CRITERION 2 
    An appropriate tool is applied to make an evidence based decision about the conditions relating to the payment of the benefit. 

    SPECIFIC OUTCOME 3 
    Analyse the benefits of a medical procedure or treatment to a patient for an exceptional case. 

    ASSESSMENT CRITERIA     

    ASSESSMENT CRITERION 1 
    Documents or available evidence relating to specific case are analysed to establish the rationale for the procedure or treatment. 

    ASSESSMENT CRITERION 2 
    The evidence required to support a possible recommendation is gathered, collated and referred to the appropriate committee, department or advisor according to the procedures of a selected medical scheme. 

    ASSESSMENT CRITERION 3 
    The patient profile is analysed to determine the potential role of the patient in the decision and improved quality of life. 

    ASSESSMENT CRITERION 4 
    The recommended international guidelines for a specific procedure or treatment are applied to determine the potential benefit to the patient and/or medical scheme. 

    SPECIFIC OUTCOME 4 
    Analyse the cost of benefits to a medical scheme of a specific procedure or treatment for an exceptional case. 

    ASSESSMENT CRITERIA     

    ASSESSMENT CRITERION 1 
    The legal and ethical responsibilities of the medical scheme are discussed with reference to non-registered drugs, unconventional treatment and new technology. 

    ASSESSMENT CRITERION 2 
    The risk profile of the medical scheme is interpreted to determine whether the scheme can afford the treatment or procedure with reference to financial and reputational risk. 

    ASSESSMENT CRITERION 3 
    The cost benefit to the scheme is analysed with reference to the impact of added costs over long term or short term benefits. 

    ASSESSMENT CRITERION 4 
    Risks associated with emotional decisions are discussed from the point of view of the patient, scheme and community. 

    SPECIFIC OUTCOME 5 
    Make a recommendation for a case under investigation. 

    ASSESSMENT CRITERIA     

    ASSESSMENT CRITERION 1 
    Evidence based data and health economics are applied to recommend a possible course of action with regard to benefits. 

    ASSESSMENT CRITERION 2 
    The proposal is substantiated with evidence from current studies, medical scheme specific data and the risk profile from general South African population data where applicable. 


    UNIT STANDARD ACCREDITATION AND MODERATION OPTIONS 
  • Anyone assessing a candidate against this unit standard must be registered as an assessor with the relevant ETQA or ETQA where a Memorandum of Understanding (MOU) exists with the relevant ETQA.
  • Any institution offering learning that will enable achievement of this unit standard must be accredited as a provider through the relevant ETQA or ETQA where a Memorandum of Understanding (MOU) exists with the relevant ETQA.
  • Moderation of assessment will be overseen by the relevant ETQA according to the moderation guidelines and the agreed ETQA procedures. 
    		•

    UNIT STANDARD ESSENTIAL EMBEDDED KNOWLEDGE 
    N/A 

    UNIT STANDARD DEVELOPMENTAL OUTCOME 
    N/A 

    UNIT STANDARD LINKAGES 
    N/A 


    Critical Cross-field Outcomes (CCFO): 

    UNIT STANDARD CCFO IDENTIFYING 
    The learner is able to identify and solve problems in which responses show that responsible decisions using critical and creative thinking have been made in making a recommendation for a case under investigation. 

    UNIT STANDARD CCFO COLLECTING 
    The learner is able to collect, organise and critically evaluate information in analysing benefits of treatment or protocols for a patient and a medical scheme. 

    UNIT STANDARD CCFO DEMONSTRATING 
    The learner is able to see the world as a set of related systems in applying knowledge of health economics to decision making. 

    UNIT STANDARD ASSESSOR CRITERIA 
    N/A 

    REREGISTRATION HISTORY 
    As per the SAQA Board decision/s at that time, this unit standard was Reregistered in 2012; 2015. 

    UNIT STANDARD NOTES 
    Search words: cost management, medical schemes, managed care. 

    QUALIFICATIONS UTILISING THIS UNIT STANDARD: 
      ID QUALIFICATION TITLE PRE-2009 NQF LEVEL NQF LEVEL STATUS END DATE PRIMARY OR DELEGATED QA FUNCTIONARY
    Elective  66611   National Certificate: Wealth Management  Level 5  NQF Level 05  Passed the End Date -
    Status was "Reregistered"     		 2023-06-30  As per Learning Programmes recorded against this Qual 


    PROVIDERS CURRENTLY ACCREDITED TO OFFER THIS UNIT STANDARD: 
    This information shows the current accreditations (i.e. those not past their accreditation end dates), and is the most complete record available to SAQA as of today. Some Primary or Delegated Quality Assurance Functionaries have a lag in their recording systems for provider accreditation, in turn leading to a lag in notifying SAQA of all the providers that they have accredited to offer qualifications and unit standards, as well as any extensions to accreditation end dates. The relevant Primary or Delegated Quality Assurance Functionary should be notified if a record appears to be missing from here.
     
    NONE 


    All qualifications and part qualifications registered on the National Qualifications Framework are public property. Thus the only payment that can be made for them is for service and reproduction. It is illegal to sell this material for profit. If the material is reproduced or quoted, the South African Qualifications Authority (SAQA) should be acknowledged as the source.