Medical scheme members must insist on their rights

2015-08-11 08:59
Lyse Comins

Lyse Comins (File)

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JASON Henley* landed up in ICU with a lung embolism and acute kidney failure after an allegedly botched operation earlier this year.

Bestmed Medical Scheme settled most of the costs directly with the hospital as a Prescribed Minimum Benefit (PMB) — a list of 270 treatments and 25 chronic conditions that medical schemes must by law under Regulation 8 of the Medical Schemes Act, cover in full. Medical schemes may also not debit a medical savings account to pay for PMBs. But the scheme refused to pay for a few items, which the hospital claimed from the patient.

Henley sought advice from SA ­National Consumer Union (Sancu) vice-chairperson Clif Johnston, who advised him of his rights and how to tackle the problem. He also has a case pending before the Health Professions Council of South Africa, regarding the procedure that went wrong, but that’s a matter for another column. Henley’s story highlights how important it is for medical scheme members to insist on their rights, even as regulators consider changes that patient rights advocacy groups fear may affect them.

Johnston said Henley asked Bestmed to explain why the full treatment had not been covered as a PMB under the law.

“Bestmed responded stating that the hospital had agreed to waive some of the charges as inappropriate, but remaining charges for a diabetic supplement were not covered and had to be paid by the patient,” he said.

Johnston said Henley had been given the supplement, which cost a few hundred rand, under doctor’s orders while he was in ICU, and he had no choice in the matter.

He escalated the complaint to the scheme’s appeal committee and then filed a complaint with the Council for Medical Schemes (CMS). However, the scheme still refused to pay.

Letters of demand from the hospital flooded in, until one day out of the blue, the medical scheme settled the account.

Bestmed CEO Dries la Grange declined to comment on Henley’s case without written consent from the member, which was too late to get at the time of going to print, except to say that each member’s case was “considered thoroughly” to ensure sustainability.

“Bestmed’s agreement with suppliers and providers is to negotiate and renegotiate better tariffs in the interest of our members. This practice ensures efficiency and effectiveness in clinical and financial risk assessment, which may apply managed health care measures,” he said.

Henley is one of thousands of consumers who have lodged complaints regarding short and non-payment of PMBs with the CMS, which in 2013/14 received 2 736 complaints about the problem, tallying 50% of all complaints received. And according to a health official, who asked not to be named because he is not allowed to speak to the media, this figure may represent a tiny ­percentage of cases because most of the country’s nine million medical scheme members don’t know their rights.

But now there are fears the Department of Health’s proposed amendments to Regulation 8 could erode members’ rights. Presently, the regulations allow for member co-payments only if a non-designated service provider is used for non-emergencies.

Patient rights groups such as People Living with Cancer, the Treatment Action Campaign and the SA Anxiety and Depression Group have raised concern that the proposed amendments limit the amount medical schemes will be forced to pay for PMBs. The amendments propose medical schemes must “pay in full” but only up to the 2006 National Health Price Reference List (NHPRL) plus inflation — which health professionals have long dismissed as not reflective of the costs of services — or at a rate medical schemes negotiate with health service providers. But advocacy groups are concerned that health professionals will continue to charge what they want, leaving patients with hefty co-payments.

Section 27 attorney Umunyana ­Rugege, who represents the groups, said the regulations were “a step backwards” as they would erode the social protection of continuous cover for diseases such as HIV, TB, cancer and emergency ­treatments.

University of the Cape Peninsular ­lecturer and former TAC COO Stephen Harrison described the wording of the amendments as “contentious”.

“The wording needs to be clarified to ensure there are no unintended consequences. A plain reading would appear to mean that the requirement to pay in full would extend only as far as the NHPRL or to an agreed tariff. If that is a correct interpretation, members would be faced with a significant co-payment gap as service providers would continue to charge in excess of the minimum ­payment,” he said.

Johnston said the problem of medical schemes refusing to pay in full for PMBs was “very widespread” and members were not aware of their rights.

“Sancu has not yet discussed the ­proposed amendments, but based on previous discussions we believe that something needs to be done to improve the current situation regarding ­prescribed minimum benefits,” he said.

Visit the CMS website for the list of PMBs.

* Name has been changed to protect ­patient’s request for privacy

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