Medical scheme members mostly complain about having to pay for PMBs

The short-payment or non-payment of bills for prescribed minimum benefits (PMBs) gave rise to the most complaints by members of medical schemes last year, the Council for Medical Schemes's latest annual report shows.

In terms of the regulations under the Medical Schemes Act, schemes are obliged to pay the costs of the diagnosis, treatment and care related to a PMB condition in full, regardless of what your doctor or other healthcare provider charges. Claims for PMBs cannot be paid out of medical savings accounts. Despite this, the payment of PMB accounts is an ongoing source of conflict between members and their schemes. Last year, the Council for Medical Schemes received 5 008 valid complaints, of which 2 736 related to the short-payment or non-payment of PMB claims.

In the category "Short-payment on PMB accounts", there were 1 027 complaints by members whose schemes refused to pay accounts at the rate charged by the doctor. Instead, schemes paid "at scheme tariff " and left members responsible for the balance. One of the biggest problems members encounter is proving that a claim was for a PMB condition. A common problem is where a bill for a diagnostic test, such as a blood test, for a PMB condition does not contain the correct diagnostic (ICD10) code, which identifies it as such.

PMBs now account for 53 percent of the total amount that medical schemes spend on benefits. The remaining contribution (excluding contributions to medical savings accounts) goes towards funding risk benefits - that is, non-PMB benefits. One way that medical schemes try to manage their PMB costs is to contract with a designated service provider (DSP) that members must use when they need treatment or medication for a PMB condition. If they don't use the DSP, they have to pay a co-payment, which must be specified in the rules of their scheme, and it could be the difference between what a DSP would have charged and what the provider charged.

The council dealt with 416 complaints relating to DSPs. This is in addition to the 1 027 "paid at scheme tariff " complaints. A large number of complaints last year related to treatment protocols. In the category "Short-payment on PMB accounts", there were 223 complaints about protocols. In the category of "Non-payment of PMB accounts", there were 200 complaints about protocols. Thembekile Phaswane, senior manager: complaint adjudication at the council, said these complaints revealed that some schemes had treatment protocols that were not evidence-based. For example, she said, some members required joint replacement surgery, but found they did not qualify in terms of the criteria set out in the clinical protocol, which says that if one's body mass index (BMI) is over 35, are not eligible for the treatment.

But there is no evidence-based literature to support why a high BMI should preclude a patient from joint replacement surgery. In addition, the clinical protocols did not provide for any assistance for a weight-loss programme for affected members. Phaswane said it is only when a member tries to access a benefit that they come across the treatment protocol, because communication from schemes tends to simply refer to the benefits being subject to a clinical protocol. She said the problem was that protocols were not made available to members, adding that treatment protocols must be given to members, service providers and members of the public on request.  A scheme's refusal to provide this is cause for complaint.

The PMB Code of Conduct states that pre-registration may be required by medical schemes, as some PMB claims cannot be correctly identified as PMBs only on ICD10 codes or medicine codes. However, such pre-registration must not place an unnecessary burden on members and must not be used as a tool to deny members access to PMBs. In the council's latest annual report, it announced that it is launching a pro bono panel of attorneys and a law clinic to help members who cannot afford legal representation in their disputes with their schemes. Although the council's appeals committee and appeals board help members, they are at a disadvantage when pitted against schemes that have legal counsel. The council has teamed up with non-profit organisation ProBono.org to ensure that members get free professional help by lawyers who sign up as volunteers.

Angelique Ardé: Personal Finance, 13 September 2014