Council knocks Keyhealth over refusal to pay for PMB condition
Medical scheme denies prescribed minimum benefits for overactive thyroid, saying the member needs to develop a ‘thyroid storm’ before qualifying
The Council for Medical Schemes (CMS) says it’s “concerning” that Keyhealth medical scheme denied a member prescribed minimum benefits (PMBs) for an overactive thyroid on the basis that she needed to develop a “thyroid storm”, which is a medical emergency, before she could qualify for PMBs.
Hyperthyroidism is a PMB condition, the council says. “This patient’s condition cannot validly be considered not to be a PMB just because her life is not in immediate danger,” the council’s clinical review committee says in a ruling against Keyhealth handed down earlier this year.
The ruling stems from a complaint lodged by healthcare rights activist Angela Drescher on behalf of a member who Drescher says was treated unfairly by Keyhealth.
The scheme at first rejected the member’s claims, saying her condition was not a PMB condition and not covered in terms of her benefit option.
The ruling says that in October 2018, the member consulted her doctor as she was experiencing severely itchy skin. Her doctor ordered blood tests to confirm a diagnosis. He diagnosed kidney problems and prescribed medication that provided no relief from the symptoms, so she sought a second opinion.
A week later, a second doctor diagnosed her with hyperthyroidism (an overactive thyroid) and thyrotoxicosis with goitre. The diagnosis was confirmed by blood test results.
In a letter of motivation to the scheme, the doctor stated that the patient’s conditions were serious and could be life threatening. He also set out the treatment she may require and prescribed medication.
Your scheme may never pay PMB claims from your medical savings account, as this is prohibited in terms of regulations under the Medical Schemes Act.The Council for Medical Schemes
A month later, the patient consulted a surgeon, who confirmed the diagnosis of hyperthyroidism and submitted a letter of motivation to the scheme stating his findings and treatment options.
The ruling says the member made several attempts to claim for the diagnostic tests, the treatment and care as well as authorisation for further tests and future treatment.
One of her consultations was with a specialist who is not one of the scheme’s designated service providers (DSPs) because the DSP closest to her home, in the Nelspruit area, is more than 200km away. After the member paid the account in full, the scheme failed to reimburse her in full.
Scheme was ‘incorrect’
After the complaint was lodged with the council, Keyhealth conceded that it had been incorrect and that hyperthyroidism was a PMB, the ruling says.
The scheme said it did not know why the member had raised the nonpayment of claims, contending that all disputed claims had been paid since the council intervened. But Drescher and the member said this wasn’t so and that some claims had been paid from the wrong benefits, namely the member’s medical savings account.
In terms of the ruling, the scheme must fund diagnostic tests, care and treatment for the member’s PMB condition in line with PMB regulations and as per the clinical opinion by the CMS’s review committee.
The scheme must also ensure that future tests, treatment and consultations for the condition are paid in line with PMB regulations, taking into consideration the level of care offered by the state, the ruling says.
The ruling notes that your scheme may pay your PMB claims from any day-to-day benefit the scheme provides as part of your risk benefits. But when this benefit is depleted the scheme must continue to pay your PMB claims. Your scheme may never, however, pay PMB claims from your medical savings account, as this is prohibited in terms of regulations under the Medical Schemes Act.
If any PMB claim was paid from your savings benefit, the scheme must reverse such payment and process it from the correct benefit, the ruling says.
The ruling ordered Keyhealth to reimburse the member for claims already paid by her for the PMB condition, which was a result of the scheme’s incorrect processing or interpretation of the claims, the council says.
Lastly, the ruling ordered the scheme to pay claims for the nonDSP specialists in full if there was no DSP within reasonable proximity from the member’s place of residence.
What is a PMB?
Prescribed minimum benefits (PMBs) are a set of defined benefits to ensure that you, as a medical scheme member, have access to certain minimum health services, regardless of the benefit option you have selected.
The aim of the PMBs is to provide members with continuous care to improve their health and well-being and to make healthcare more affordable, the CMS says.
PMBs are a feature of the Medical Schemes Act, in terms of which medical schemes have to cover the costs related to the diagnosis, treatment and care of:
- Any emergency medical condition;
- Twenty-five common chronic conditions; and
- A limited set of 270 medical conditions (defined in the Diagnosis Treatment Pairs, which you can find on the council’s website).
The 25 common chronic conditions are:
- Addison’s disease
- Bipolar mood disorder*
- Cardiac failure
- Chronic obstructive pulmonary disorder
- Chronic renal disease
- Coronary artery disease
- Crohn’s disease
- Diabetes insipidus
- Diabetes mellitus types 1 & 2
- Multiple sclerosis
- Parkinson’s disease
- Rheumatoid arthritis
- Systemic lupus erythematosus
- Ulcerative colitis
* Will only be covered when an algorithm has been developed.