{"id":153211,"date":"2025-11-26T03:48:13","date_gmt":"2025-11-26T03:48:13","guid":{"rendered":"https:\/\/www.newsbeep.com\/il\/153211\/"},"modified":"2025-11-26T03:48:13","modified_gmt":"2025-11-26T03:48:13","slug":"pmcare-advocates-for-doctors-tpa-more-than-middleman","status":"publish","type":"post","link":"https:\/\/www.newsbeep.com\/il\/153211\/","title":{"rendered":"PMCare Advocates For Doctors, TPA More Than \u2018Middleman\u2019"},"content":{"rendered":"

SUBANG JAYA, Nov 26 \u2014 PMCare Sdn Bhd vociferously opposes the \u201cmiddleman\u201d label that some medical practitioners attach to third-party administrators (TPAs) or managed care organisations (MCOs) in Malaysia.<\/p>\n

In an exclusive interview with CodeBlue that shed rare light on the behind-the-scenes workings of a TPA in health care management, PMCare\u2019s leadership team explained that they actually seek to endorse clinicians\u2019 treatment plans to their \u201cpaymasters\u201d: insurance and corporate clients.<\/p>\n

\u201cWe have evolved to more than just a \u2018middleman\u2019,\u201d said PMCare chief medical officer Dr Muhammad Ainuddin Mohamad Rusli during the interview last Thursday with his colleagues, including representatives from the company\u2019s owner, Sumitomo Corporation, at PMCare\u2019s office here.<\/p>\n

\u201cWe have become advocates of hospitals and consultants, so we never reject technical advancements and all the decisions by the consultants.\u201d<\/p>\n

\"\"PMCare chief medical officer Dr Muhammad Ainuddin Mohamad Rusli. Photo by Saw Siow Feng for CodeBlue.<\/p>\n

Dr Ainuddin explained that, for example, PMCare\u2019s insurance clients consider laparoscopic surgery to be robotic surgery, which is only covered for prostate, fibroids, and ovarian cysts even though robotic surgery isn\u2019t new.\u00a0<\/p>\n

But PMCare advised its clients that laparoscopic surgery should be defined as minimally invasive surgery that would then merit coverage, rather than robotic surgery.<\/p>\n

\u201cWe explain to them the advantages of robotic surgery or all the technological advancements in medicine because it\u2019s not only cost that should be the concern, but productivity. We know that usually, less complications are reported and you have faster recovery,\u201d said Dr Ainuddin.<\/p>\n

\u201cThis is where we come in as a TPA to our clients. From this point of view, we should be seen as associates of our providers by trying to explain to clients why these treatments should be considered.\u201d\u00a0<\/p>\n

PMCare chief executive officer Kamal Aryf Baharuddin said his company has urged hospitals to charge robotic surgery at the same price as conventional surgery; health care providers usually charge up to 30 per cent higher for robotic surgery.<\/p>\n

CodeBlue previously reported <\/a>that robotic surgery technology costs about US$2 million (RM8.9 million) to US$3 million (RM13.2 million) internationally.<\/p>\n

\u201cHospitals have already invested in this expensive device, but you\u2019re not getting patients because the paymaster is not going to pay,\u201d said Kamal.<\/p>\n

Private hospitals demur, he noted, as they cite high capex. \u201cWithout them working towards this, it will be difficult to convince the insurance company and paymaster because they\u2019re saying, \u2018this is part of our cost-containment\u2019,\u201d Kamal lamented.<\/p>\n

\"\"Standing is PMCare chief executive officer Kamal Aryf Baharuddin, followed by (clockwise) Takuma Wada (representative from Sumitomo Corporation), PMCare chief medical officer Dr Muhammad Ainuddin Mohamad Rusli, PMCare operations head Syahrul Nizam Baharuddin, PMCare claims director Dr Armijn Mahpha Fansuri, Ayaka Onoe (representative from Sumitomo Corporation), and CodeBlue editor-in-chief Boo Su-Lyn. Photo by Saw Siow Feng for CodeBlue.<\/p>\n

Another common exclusion, according to PMCare, is hyaluronic acid (HA) injections for knee osteoarthritis. Insurers also don\u2019t cover congenital diseases.<\/p>\n

PMCare \u2013 a 30-year-old company that pioneered the concept of managed care in Malaysia \u2013 is 100 per cent owned by Japan\u2019s Sumitomo Corporation, a Fortune Global 500 company, after Ekuiti Nasional Berhad (Ekuinas) divested its entire 60 per cent stake from the TPA in 2019.\u00a0<\/p>\n

For its insurance clients, PMCare manages their group policies for companies, whereas its corporate clients self-pay for employee benefit schemes. PMCare, the oldest TPA in Malaysia, has serviced more than 2,000 clients since its inception in 1995.\u00a0<\/p>\n

Its insurance clients include insurers and takaful operators, whereas its corporate clients comprise government-linked companies, multinational corporations, banks, and even private hospitals.<\/p>\n

\u2018We Never Question Treatment Decisions\u2019<\/p>\n

\"\"PMCare claims director Dr Armijn Mahpha Fansuri. Photo by Saw Siow Feng for CodeBlue.<\/p>\n

According to Kamal, claims or guarantee letters (GLs) issued by PMCare are usually handled by non-doctor staff, guided by parameters in its system based on the client\u2019s policy or schedule of benefits. If cases need to be escalated, they are brought up to medical doctors in the company. PMCare employees dealing with hospitals are doctors.<\/p>\n

PMCare has 15 medical doctors, which Kamal noted is far more than insurance companies that usually only have two to three doctors. None of PMCare\u2019s doctors are specialists.<\/p>\n

\u201cAt PMCare, we pride ourselves with good questions when we query doctors for every claim,\u201d said PMCare claims director Dr Armijn Mahpha Fansuri.<\/p>\n

He said PMCare doesn\u2019t ask clinicians broad questions like, \u201cwhy are you doing this procedure?\u201d<\/p>\n

\u201cWe actually query in a way that the doctors understand what we actually want to know and find out, rather than a basic old-school open question.\u201d<\/p>\n

Dr Ainuddin acknowledged that certain consultants may perceive PMCare as questioning their treatment decisions, but he insisted that the TPA doesn\u2019t do so, nor tell doctors, \u201cyou shouldn\u2019t do this\u201d or \u201cyou must do this\u201d.<\/p>\n

\u201cOnce they decide on certain treatments, then we say \u2018fine, that\u2019s the medical expertise decision\u2019,\u201d he said. \u201cBut what we\u2019re trying to educate or bring the message to the consultant is that they have to understand that according to our client\u2019s policy, the treatment modality that they decided to go for is non-reimbursable.\u201d<\/p>\n

Dr Armijn said the doctor or hospital, not PMCare, is responsible for telling an insured patient that a particular drug or procedure isn\u2019t covered.<\/p>\n

\u201c\u2018Not covered\u2019 doesn\u2019t mean \u2018no, I cannot treat you\u2019,\u201d he said. \u201c\u2018I can still treat you\u2019.\u201d<\/p>\n

CodeBlue disputed this, pointing out that denials effectively result in patients being unable to access treatment, since Malaysians in general can\u2019t afford to pay out of pocket for care in private hospitals; hence why they take up insurance in the first place.<\/p>\n

\"\"Prior to issuing a guarantee letter, a PMCare call centre agent utilises the company\u2019s rule-based engine to verify the request against parameter sets derived from the client\u2019s policy or schedule of benefits. Photo by Saw Siow Feng for CodeBlue.<\/p>\n

Kamal then intervened and said when clients are onboarded, PMCare explains to their clients\u2019 employees about what\u2019s covered or not in benefit schemes, citing maternity as an exclusion. He said patients sometimes don\u2019t know that they\u2019re pregnant when they go to a hospital after suffering symptoms.<\/p>\n

\u201cIt turns out to be an ectopic pregnancy, for example,\u201d he said. \u201cAs far as the company is concerned, they don\u2019t cover it, but the hospital has to give treatment.\u201d<\/p>\n

Such medical emergencies, Kamal said, put the TPA in a predicament.\u00a0<\/p>\n

\u201cThis is where we actually try to argue on behalf of the patient first and then explain later to their employer,\u201d said the PMCare CEO. \u201cThe employer says, \u2018the employee should know\u2019, but how to prove that the employee should know when they probably didn\u2019t know they were pregnant?\u201d<\/p>\n

60-Day Payment Term For Providers, RM104 Million In Past Due Claim Receivables<\/p>\n

\"\"A PMCare call centre agent responds to member queries. Photo by Saw Siow Feng for CodeBlue.<\/p>\n

PMCare has 352 staff, with the company taking up three floors of Menara Insignia in Subang Jaya.<\/p>\n

Kamal explained that before the formation of TPAs or MCOs in Malaysia, after an insured patient sees a panel general practitioner (GP) or gets admitted to a private hospital, the health care provider sends the bill to the human resource (HR) department of the patient\u2019s employer. Finance will then pay the bill.<\/p>\n

The problem arises when admission occurs at night, as HR doesn\u2019t work after hours. Hence, MCOs came in to fill that gap to enable cashless treatment 24\/7, which then allowed companies to focus on their core business instead of allocating a lot of human resources for redundant and repetitive work.<\/p>\n

\u201cTPAs are an extension of HR; we\u2019re also an extension of an insurance company\u2019s role,\u201d said Kamal.<\/p>\n

\"\"These dashboards at PMCare\u2019s call centre provide real-time monitoring of final guarantee letter issuance, tracking claims submitted via both Medibase portals and API e-billing. Photo by Saw Siow Feng for CodeBlue.<\/p>\n

TPAs offer payers cost containment, governance, reduced leakage, fraud control, and reporting. Providers, on the other hand, benefit from patient volume and marketing, administrative efficiency, financial guarantee, and not needing to chase multiple corporations for payment.<\/p>\n

PMCare boasts the largest panel network of medical providers nationwide with cashless access in Malaysia, at nearly 7,300 panel providers comprising 5,280 GP clinics, 1,163 dental clinics, 492 specialists or hospitals, and 337 optical clinics.<\/p>\n

\u201cFor providers, they\u2019re interested to be part of the panel because they will get access straight away to the headcount and patients,\u201d said Kamal. \u201cOtherwise, if you just start a business without going to PMCare, you need to knock on every single door of corporations \u2013 \u2018Can I be on your panel?\u2019\u201d<\/p>\n

\"\"PMCare call centre staff meticulously check and confirm all information and documents received from members and hospitals as a crucial step preceding the issuance of a guarantee letter. Photo by Saw Siow Feng for CodeBlue.<\/p>\n

PMCare\u2019s revenue comes from two sources: a service subscription fee for payers (self-insured enterprise or insurance company) and a platform fee for providers (hospital or clinic).<\/p>\n

In three decades, PMCare\u2019s subscription fee for payers dropped by 40 per cent from RM60 per insured person per year in 1995 to a maximum of RM36 currently, due to a \u201cprice war\u201d among TPAs to get corporate clients. \u201cWhen your fees go down, you have to be efficient,\u201d said Kamal.<\/p>\n

Unlike other TPAs that charge providers a percentage of the latter\u2019s fees, like 10 to 15 per cent, PMCare\u2019s platform fee for providers is a fixed rate of RM8 per patient per approved transaction. \u201cIf it\u2019s not approved, we won\u2019t charge the doctor.\u201d<\/p>\n

\"\"These dashboards at PMCare\u2019s call centre display key metrics for call centre performance (calls in\/out) and the progress of guarantee letter issuance for both outpatient specialist clinics and hospital admissions. Photo by Saw Siow Feng for CodeBlue.<\/p>\n

PMCare\u2019s commitment to panel providers, including GP clinics, is a payment term of not more than 60 days. Sumitomo initially wanted a 30-day payment term, like what is practised in Japan, but PMCare is unable to do so because not all of its clients pay on time.<\/p>\n

PMCare reported claim receivables of a whopping RM233 million last year, comprising RM129.5 million not past due, RM62.5 million past due one to 30 days, and RM41 million past due 31 to 120 days, requiring the TPA to manage its cashflow.<\/p>\n

\u201cPeople do not see this,\u201d lamented Kamal. \u201cPeople just say, \u2018middleman middleman middleman\u2019.\u201d<\/p>\n

When CodeBlue suggested that PMCare complain about clients not paying on time, Kamal laughed and said, \u201cIf we complain, then they will go to another TPA.\u201d<\/p>\n

In response to some doctors criticising TPAs for \u201cdouble-dipping\u201d <\/a>by charging both corporations and clinics, the PMCare CEO said, \u201cThey do not know in reality how much a TPA is suffering.\u201d<\/p>\n

PMCare pays GPs a consultation fee of RM34 on average across the country; in Selangor and Kuala Lumpur, the fee ranges from RM35 to RM36. \u201cWe know that some TPAs actually fix RM18,\u201d Kamal noted. \u201cI think Starbucks coffee is more expensive than that.\u201d<\/p>\n

IT Programming, Data Analytics, Tour Of Call Centre<\/p>\n

\"\"Final GL team members at PMCare assess and adjudicate invoices received from hospitals before issuing the final GLs. Photo by Saw Siow Feng for CodeBlue.<\/p>\n

Kamal dislikes the term \u201cmiddleman\u201d as he thinks it implies as if TPAs just process transactions without doing anything further, like \u201cI just look, okay, bye.\u201d<\/p>\n

\u201cWe\u2019re doing more than that,\u201d he said.\u00a0<\/p>\n

Managed care services at PMCare comprise medical management (medical audit, utilisation review, and wellness initiatives); administrative services (hassle-free claims adjudication, 24\/7 careline, and a mobile app for members or insured people); and provider network management (cashless treatment, nationwide provider access, and medical cost containment).<\/p>\n

PMCare employs 40 IT programmers and eight or nine data analytics staff. Its data analytics team does predictive modeling on health outcomes linked to behaviour, enabling the company to provide health care or disease management solutions for an overall cost containment strategy.<\/p>\n

Kamal said PMCare also provides anonymised data to the Ministry of Health (MOH), like GP charges as requested last week by regulators.<\/p>\n

Besides tracking the status of GLs or claims, PMCare\u2019s mobile app for members has other features like teleconsultations, home delivery of long-term medications, personal health records, and assessments for health risk and mental health.<\/p>\n

\"\"PMCare\u2019s senior IT manager providing an explanation of the system\u2019s performance metrics shown on a monitoring room dashboard, including transaction parameters and processing speed. Photo by Saw Siow Feng for CodeBlue.<\/p>\n

When CodeBlue asked if TPAs add on to the cost of health care due to their role as so-called \u201cmiddlemen\u201d, Kamal disagreed, saying that PMCare looks at overall cost containment based on data, rather than cherry-picking certain items.<\/p>\n

\u201cEven if it\u2019s two ringgit, if it\u2019s not justifiable, we will not approve it,\u201d he said. \u201cBut if it\u2019s 100 ringgit and it\u2019s justifiable, even though people may say this is expensive, we will approve it if it\u2019s necessary.\u201d<\/p>\n

Kamal took the CodeBlue team on a tour around PMCare\u2019s call centre and departments across three floors: provider network management (Level 11); health care solutions, client solutions, client servicing, enrolment, and call centre (Level 12); and claims, data analytics, and IT department (Level 13).\u00a0\u00a0<\/p>\n

PMCare\u2019s call centre has 83 employees, comprising 45 to attend calls and issue GLs, plus another 38 managing discharge advice or final GLs.<\/p>\n

\"\"A Final GL team member at PMCare performs claims verification using claims data received via API, preceding the claims adjudication based on the schedule of benefits or policy. Photo by Saw Siow Feng for CodeBlue.<\/p>\n

Staff showed CodeBlue how initial GLs for admission and final GLs for discharge are issued from PMCare\u2019s proprietary system, which reduces dependency on personnel, as the rule-based processing engine evaluates claims based on diagnosis, hospital tier, and patient age.\u00a0<\/p>\n

Exclusions automatically flagged by the system prompt PMCare staff to further query GL requests from a hospital, following a digital preadmission form filled up by the attending doctor. PMCare\u2019s commitment is to issue GLs for admission within 30 minutes. Delays, said Kamal, are very rare.\u00a0\u00a0<\/p>\n

PMCare has various live dashboards on the wall in their call centre, showing the status of claims processing for admission and discharge. Staff also showed CodeBlue the features of its IT system, like the speed of transactions.<\/p>\n

PMCare processes more than 13,000 claims on average per day.<\/p>\n

\u201cWe are part of bringing value to the health care ecosystem,\u201d said Kamal.<\/p>\n","protected":false},"excerpt":{"rendered":"SUBANG JAYA, Nov 26 \u2014 PMCare Sdn Bhd vociferously opposes the \u201cmiddleman\u201d label that some medical practitioners attach…\n","protected":false},"author":2,"featured_media":153212,"comment_status":"","ping_status":"","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[34],"tags":[93067,163,521,85,46,93068,3983,51677],"class_list":{"0":"post-153211","1":"post","2":"type-post","3":"status-publish","4":"format-standard","5":"has-post-thumbnail","7":"category-healthcare","8":"tag-clinical-decisions","9":"tag-health","10":"tag-healthcare","11":"tag-il","12":"tag-israel","13":"tag-managed-care-organisations-mcos","14":"tag-medical-insurance","15":"tag-third-party-administrators-tpas"},"_links":{"self":[{"href":"https:\/\/www.newsbeep.com\/il\/wp-json\/wp\/v2\/posts\/153211","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.newsbeep.com\/il\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/www.newsbeep.com\/il\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/www.newsbeep.com\/il\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/www.newsbeep.com\/il\/wp-json\/wp\/v2\/comments?post=153211"}],"version-history":[{"count":0,"href":"https:\/\/www.newsbeep.com\/il\/wp-json\/wp\/v2\/posts\/153211\/revisions"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/www.newsbeep.com\/il\/wp-json\/wp\/v2\/media\/153212"}],"wp:attachment":[{"href":"https:\/\/www.newsbeep.com\/il\/wp-json\/wp\/v2\/media?parent=153211"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/www.newsbeep.com\/il\/wp-json\/wp\/v2\/categories?post=153211"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/www.newsbeep.com\/il\/wp-json\/wp\/v2\/tags?post=153211"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}