Picture: AFP/JEFF PACHOUD
Picture: AFP/JEFF PACHOUD

Medical schemes continue to fail to pay or short-pay members' claims for prescribed minimum benefits (PMBs), sparking complaints to the medical schemes regulator.

The Council for Medical Schemes (CMS) says in its latest annual report that 1,242 of 3,808 complaints lodged last year related to PMBs - benefits that schemes are legally obliged to cover.

It also notes that some schemes are still using members' medical savings accounts, rather than scheme funds, to pay for the treatment of PMBs. This is a contravention of the law, yet when picked out about it by the regulator the schemes concerned offered no explanation but merely advised that the relevant accounts had been reversed and reprocessed to pay from the scheme's risk benefit.

There is a lot to be
done by all
stakeholders in
educating members
Grace Khoza, spokesperson for the Council for Medical Schemes

The annual report states that this conduct shows more work needs to be done by the council to ensure full compliance by medical schemes and their administrators with the application of the law, "and that there must be consequences for those entities who contravene the [Medical Schemes] Act".

One of the regulations under the act states that schemes must pay PMB claims in full regardless of what the doctor or other health-care provider charges. But last year there were 285 complaints about schemes that paid PMB claims at lower scheme rates.

The annual report does not record how many of these complaints were resolved in members' favour, but problems arise when schemes appoint designated service providers (DSPs) that members must use to enjoy full cover for PMBs.

A way to contain costs

This is the only way the law provides for schemes to contain the cost of providing the PMBs, and if you fail to use the DSP, your scheme can impose a co-payment.

This co-payment that the scheme will not cover must be quantified in the scheme's rules and it cannot be applied if you were unable to use the DSP because it was an emergency, the provider wasn't able to see you within a reasonable time, or wasn't within a reasonable distance from your home or workplace.

Grace Khoza, spokesperson for the council, says sometimes it appears that a scheme has paid a member's PMB claims at the scheme tariff rather than in full, in contravention of the law.

But on further probing, it may emerge that the scheme paid its own rate because the member failed to use the DSP.

The council's complaints unit then has to determine whether the member chose to use a provider other than the designated one or whether the use of such a provider was involuntary.

The annual report notes that there were 106 complaints about DSPs and 178 about non-designated service providers.

There were also 98 complaints about the short-payment of PMB claims that schemes stated were a result of the claims being beyond scheme protocols, and 31 that were short-paid because the medication was not on the scheme's formulary.

Schemes are allowed to draw up treatment guidelines, or protocols, and lists of essential medicines for PMBs as long as you do not get less treatment than you would in a state clinic or hospital.

It is hard to know what you would be entitled to in a state facility and finding this out can be a huge burden when you are ill.

Khoza says: "Anecdotal evidence points to a lack of understanding in this space." Schemes have an obligation to inform you of formularies applicable in the management of your chronic conditions, she says.

"Formularies and protocols must be furnished to treating providers, upon request. A co-payment can only be imposed if a member knowingly declines to use formulary medicine without any evidence of clinical inefficacy or adverse effects.

"Such a member should have been informed of available formularies so that he or she may discuss this with the treating doctor. Nevertheless, there is a lot to be done by all stakeholders in educating members about these issues, which can be quite complex . to understand."

Recently the Competition Commission's health market inquiry recommended that the PMBs be revised as a standardised basic benefit package for all schemes, which would include primary health-care and preventative health-care services.

Simpler package needed

33%

Of complaints about medical
schemes concerned minimum
benefits that schemes are
obliged to cover

It suggested a simpler, less ambiguous package be designed with treatment plans and formularies developed by the CMS.

The council's annual report also shows 48 complaints about incorrect coding and 53 about outstanding information on PMB claims. Members often struggle to get providers to code claims correctly so that schemes will pay them as PMBs.

Khoza says the council is unable to apportion blame to either doctors or medical schemes for these complaints as coding is complex.

The health market inquiry has recommended that the coding of medical bills be regulated by a new regulator and noted that it is integral for a good payment system.

The CMS's annual report notes that it had a backlog of complaints and was able to reduce the number of complaints by channelling certain health-care providers' complaints directly to schemes, resulting in a big drop in the number of complaints.

Last year the CMS opened files for 3,808 complaints compared with 4,667 in 2017.

The total number of complaints resolved in the year, however, was significantly higher than in 2017, with an improved resolution rate of 33%, the annual report says.

The turnaround time to resolve 47% of complaints was, however, still more than 120 days, which is particularly problematic for members who need issues related to treatment resolved quickly.

There were 2,823 complaints against open medical schemes, and the council found in favour of the complainants in fewer than half of the cases, 1,146.

By contrast, the council found mostly in favour of complainants who had beefs with restricted medical schemes - 1,081 out of a total of 1,904.

Most complaints that resulted in a ruling against a scheme or administrator were of an administrative nature, for example when benefits were paid incorrectly, or when the complaint related to pre-authorisation, among other things.