Negotiate healthcare tariffs: Sama

2011-11-08 13:15
Johannesburg - Medical schemes should be able to negotiate tariffs with hospitals, clinics and doctors, the SA Medical Association (Sama) said on Tuesday.

It was reacting to a court ruling that medical schemes should pay for conditions in full which are covered under the prescribed minimum benefits (PMB), rather than up to the scheme tariff.

PMBs are the minimum level of diagnosis, treatment and care that a medical scheme is obliged by law to cover.

Sama chairperson Dr Norman Mabasa welcomed the ruling from the North Gauteng High Court, but said it was an issue that should never have ended up in court.

"This was not a misunderstanding of the PMB rules," he said, "but a development that can be directly attributed to absolutely no mechanism being available for providers and schemes to negotiate on tariffs and possible issues surrounding them."

Revisit tariff negotiation

He said he hoped medical schemes would join Sama in lobbying for a Competition Commission ban on health tariff negotiation to be revisited.

On Monday, the court ruled that PMB, which protect members of medical schemes, would remain in place.

The Board of Healthcare Funders (BHF) had asked the court to rule on regulation eight of the Medical Schemes Act 131 of 1998. The regulation states that medical schemes must pay for the diagnosis, treatment and care of all PMB conditions in full, or at the price charged by the healthcare provider.

The scheme must pay for all PMB conditions in full and from its risk pool, not from a clients' savings account. These benefits include 270 serious health conditions such as tuberculosis and cancer, any emergency condition, and 25 chronic diseases, including epilepsy, asthma and hypertension.

In court, the BHF represented a number of medical schemes and administrators. It was later joined by the SA Municipal Workers' Union national medical scheme.

In a statement on Tuesday, the BHF said it was disappointed that the merits and principles of the matter had not been considered by the judge.

Technical points

"There is therefore still no judicial pronouncement on the correct interpretation of regulation eight," the organisation said.

"Essentially, the judgment upheld the technical points raised by the respondents and the case was dismissed on the basis that BHF, as an industry body, lacks the necessary standing to have brought this matter to court."

It would consider the judgment and its legal options, and would also seek a meeting with Health Minister Aaron Motsoaledi.

The Council for Medical Schemes, the first of 13 respondents in the case, welcomed the ruling on Monday.

"Prescribed minimum benefits are a cornerstone of the Medical Schemes Act and they were included in legislation for a good reason: to protect beneficiaries against unforeseen ill health that may prove financially catastrophic for them," council CEO Monwabisi Gantsho said. Gantsho is also the registrar of medical schemes.

"As the regulator tasked with looking after the best interests of medical scheme beneficiaries, we are happy that our courts have confirmed the need for such protection in law."

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