Dispute over doctor's fees

By Laura du Preez

A court challenge that could affect how much your medical scheme pays your healthcare provider may remain unresolved for months, with the threat of a large increase in the guideline tariffs hanging over medical schemes and members.

The legality of the Department of Health's 2009 Reference Price List (RPL), which schemes use to set benefit rates, and doctors and other healthcare providers use to set their service rates, is being challenged.

The South African Private Practitioners Forum (SAPPF), 20 other medical professions' associations, the Hospital Association of South Africa (Hasa), and emergency ser-vices providers ER24 and Netcare 911 allege that the 2009 RPL process was illegal and procedurally unfair.

Judge Piet Ebersohn reserved his judgment this week, but not before he granted an interim interdict that prevents the health department from producing any new tariff lists until the matter is resolved. Kerry Williams, the Webber Wentzel attorney for the SAPPF and the other associations, says this means the RPL, which should be published in September, may not be published until any appeals are finalised.

No list was published for 2010. Last year, with the court action pending, Health Minister Aaron Motsoaledi announced "an interim and temporary" increase of 7.9 percent in the tariffs.

Much of the arguments in the North Gauteng High Court this week related to whether the Department of Health followed the National Health Act regulations and was fair to providers during the RPL process. At issue is the health department's call for, and sub-sequent rejection of, healthcare providers' practice cost studies.

The department rejected most providers' cost studies for failing to meet the required sample sizes, or having unacceptable costing or coding methodologies.

Court papers reveal that the department was unable to verify any of the cost studies, because this was "too cumbersome and time-consuming". It then simply applied a 10.7-percent increase to the 2008 RPL and published it as the 2009 RPL.

The SAPPF and the other associations say the department incorrectly rejected the cost studies, and should have at least considered other aspects of the submissions, such as the suggested new codes and various anomalies in the RPL.

The practitioners argue that the guideline rates are now too low to cover many practices' costs.

ER24 and Hasa are arguing that the RPL regulations are not valid and that the department's rejection of their alternative costings methodologies is unfair. The health department has defended its actions and is challenging the SAPPF and the other associations' right to bring the application.