Unpaid claims for those medical emergencies create more trauma
The trouble starts with disputes about what an 'emergency' is
Sophie's* three-year-old daughter fell into their glass coffee table, cutting her head. Sophie rushed her to casualty at Mediclinic's Constantiaberg hospital.
Even though they are members of Discovery Health Medical Scheme, and all schemes are by law obliged to cover in full the cost of medical emergencies, Sophie was asked to pay upfront for the treatment or take the child to a state hospital.
Joan Green took her 73-year-old husband, Ian, to the emergency room at Netcare Blaauwberg Hospital when he couldn't walk because his knees and ankles were inflamed.
He had X-rays, scans and blood tests before he was given a script, referred to a specialist and sent home.
The Greens then got a R9,200 bill that their scheme, Discovery Health, rejected for payment. They pondered the merits of paying R3,200 a month in contributions only to find such a large bill for their account.
Fortunately for the Greens, though Ian's condition turned out to be something less than an emergency, healthcare consumer rights activist Angela Drescher encouraged them to resubmit the claim. The bill was subsequently settled by their scheme.
And while Sophie's scheme declined her claim for her daughter's bills, a claim on her gap-cover policy brought some relief.
The percentage of South Africans who will suffer a disability in their lifetime, FMI says
These cases show that, despite medical emergencies being covered by the prescribed minimum benefits (PMB), views differ on what constitutes an emergency.
David Green, divisional head of health at Med ClaimAssist, a division of Constantia Insurance Company, says schemes are not paying many of the emergency claims they should. He says of the 4,109 claims submitted to the insurer since March, close to 240 were for medical emergencies.
His data shows that the claims totalled R4.8m but schemes failed to pay some R2.7m.
The worst offenders, he says, are Medshield Medical Aid Scheme and four Discovery Health-administered restricted schemes: LA Health Medical Scheme, Quantum Medical Aid Society, Bankmed and TFG Medical Aid Scheme.
Discovery Health Medical Scheme, the country's largest open scheme, was also cited by Green for failing to pay more than 60% of what it should have in claims for emergencies that came to Med ClaimAssist.
However, Discovery's principal officer, Nozipho Sangweni, says Green's comments are based on a very small sample of claims, of which only 130 related to the open scheme. In some cases, she says, whether the situation was truly an emergency might be disputed, or Med ClaimAssist might believe some claims were PMB emergencies when they were not. Discovery has not been able to check the claims submitted to Med ClaimAssist, she says.
Sangweni says the scheme paid R26bn in PMB claims in 2017, representing 93c out of every R1 of PMB claims.
Unpaid claims mainly related to cases where members had not used the designated provider, providers charged more than agreed rates, chronic medicine limits applied, the treatment was beyond the PMB level or the claim was incomplete or had incorrect information.
Eight years ago medical schemes got together and agreed that if you, as a scheme member, visited the emergency rooms in the middle of the night because, say, your young adult child had rolled his car and needed some scans to prove he really only had a few bruises, if you mistook your elderly aunt's panic attack for a heart attack, or your toddler's virus resulted in a dangerous temperature spike in the middle of the night, the treatment should be covered until such time as the medical professionals informed you there was no emergency.
Schemes and the Council for Medical Schemes (CMS) drew up the PMB Code of Conduct, which says that when a medical emergency is provisionally diagnosed but is not yet confirmed by additional medical evidence, your scheme will be held liable to cover the costs as PMB benefits up to the stage where a PMB condition has been excluded.
Drescher noticed on the clinical notes from Green's visit to the emergency rooms that they were checking for deep-vein thrombosis.
Although he didn't have this condition, it meant that, in terms of the code, the diagnostic tests done to determine what was wrong with him had to be covered.
But if your condition isn't considered serious enough to be an emergency, you could be asked to pay upfront for your treatment, as Sophie was asked to do.
Drescher says in cases where patients are not admitted to hospital or triaged red, members are reporting that casualty rooms are demanding a triage fee upfront or presenting bills for immediate payment if their day-to-day benefits are exhausted.
No amount of blood or trauma appears to count, as the hospitals have realised that unless your emergency is clearly a PMB, you need to have day-to-day benefits to cover the cost and in the second half of the year many members no longer have funds in their medical savings accounts.
Regulations under the Medical Schemes Act dealing with PMBs state that medical emergencies shouldn't be paid from your medical savings account, but the definition of an emergency is open to interpretation.
The regulations state that an emergency is the sudden or unexpected onset of a condition that requires treatment, where failure to provide that treatment would result in serious impairment or dysfunction of an organ or part of your body or would put your life in jeopardy.
Members say hospital casualty rooms are demanding fees upfront
Tertia Kruger, corporate communications manager for Mediclinic, says the hospital group uses the triage process to determine whether a case is a true emergency.
If it is, you will be treated and billed afterwards.
However, when your case is not deemed eligible for PMB cover, you will be asked to sign a statement of liability for the account. Despite members' reports, you will not be asked to pay upfront, Kruger says.
Schemes and gap cover providers have realised that members face uncertainty around their cover in emergencies, and some are now offering benefits specifically to cover these situations.
Last year the CMS and medical scheme stakeholders met to revise the PMB Code of Conduct.
A new code was drafted and released for discussion last year, but remains a draft. The new code encourages schemes to proactively identify PMB claims, to give you three years to dispute a claim that was not correctly identified clinically as a PMB one and obliges schemes to pay for clinical motivations requested for PMBs.
* Not her real name.
Your medical emergency first-aid kit
All medical emergencies are prescribed minimum benefits that medical schemes are obliged by law to cover in full, regardless of what the healthcare provider charges to treat you.
• Medical schemes are allowed to name certain facilities or doctors as designated service providers (DSP) and insist you use them to get full cover for PMB conditions. But in an emergency, if you use a non-DSP facility or doctor, you will be regarded as having involuntarily sought healthcare services and your scheme must still pay.
• No PMB claims can be paid from your medical savings account.
• If your scheme refuses to pay a claim, stating it has no proof that it was a medical emergency, you need to get the doctor to provide clinical motivation to the scheme.
• Providers who perform diagnostic tests, such as X-rays or blood tests, won't put an ICD-10 diagnostic code on your claim that identifies your condition. Instead they use Z-codes for yet-to-be-diagnosed conditions. To get these claims paid as PMBs you may have to ask the doctor to send a request to the radiologist or pathologist to recode the claim and resubmit it to your scheme.
• A fractured limb may or may not qualify as a PMB.
Benefits for visits to casualty
If your medical scheme or gap cover provider has benefits for visits to casualty, your visit will be paid up to that benefit, regardless of whether it is regarded as a PMB. Jill Larkan, head of healthcare consulting at GTC, says schemes that offer options with casualty benefits paid from risk contributions rather than your medical savings account include:
• Fedhealth: Authorisation required, paid at scheme rates after a R550 co-payment for non-PMB events, depending on the option.
• KeyHealth: No co-payment, no limits.
• Makoti: R10,000 a beneficiary a year.
• Medihelp: R2,050 per family a year.
• Momentum: Impact and Ingwe options offer one visit per beneficiary per year. Maximum two per family. R100 co-payment.
• Resolution: R1,680 a year.
• Selfmed: R1,000 a year.
Gap cover is insurance that covers gaps in your medical scheme cover - largely shortfalls arising when doctors charge more than the scheme rate. GTC's gap cover survey identified 55 gap cover insurance policies that provide benefits for medical scheme members and their dependants who are treated in casualty or emergency wards.
Although this isn't a key criterion for choosing a gap-cover policy, they are nice to have and range between R1,000 and R15,000. The highest benefits are on Renasa's Linksave and Total Risk Administrators' policies, says Jill Larkan, head of healthcare consulting at GTC.