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Medical scheme members loose out on PMB claims

By Laura du Preez

Lack of knowledge of your rights means that you, instead of your medical scheme, may be paying for the treatment of conditions covered by the Prescribed Minimum Benefits. We report on how you may be misled into believing that claims for these essential benefits are for your account.

Medical schemes are not paying a “substantial portion” of the Prescribed Minimum Benefit (PMB) claims they should be paying, leaving you, the member, to pay these bills from your medical savings account or out of your own pocket, the latest annual report of the Council for Medical Schemes (CMS) says.

This conclusion was drawn from an audit the council conducted recently to help it understand how medical schemes implement the PMBs, the CMS’s 2008/9 annual report says.

The PMBs are essential benefits that all medical schemes are obliged by law to provide.
They ensure that you have access to cover for essential healthcare needs.

But although these benefits are protecting members when it comes to care in hospital and 27 common chronic conditions, members are not enjoying the protection they should for PMB services rendered out of hospital. Many members are oblivious to this because they are not well informed about their rights.

The council’s audit of four large medical schemes – Discovery Health Medical Scheme, Medihelp, Fedhealth and the Chartered Accountants Medical Aid Fund – found that 20 percent of PMB claims were not paid at all.

In addition, nine percent of PMB claims were paid from medical savings accounts, despite the fact that regulations under the Medical Schemes Act prevent schemes from paying PMB claims from your medical savings account.

The CMS’s report notes that Remgro’s medical scheme, Remedi, wrongly deducted co-payments on PMBs from members’ savings accounts for two years and now owes members almost R9 million.

The CMS audit was conducted on the basis of claims data and the ICD-10 codes used by healthcare service providers.

The CMS annual report says the audit showed that schemes tend to associate the PMBs (other than those for certain chronic conditions) with hospitalisation, and it is mostly PMB claims for out-of-hospital conditions that are not being paid.

However, the Medical Schemes Act, which governs the PMBs, does not limit them to services provided in hospital. You can be treated for a PMB in any appropriate setting.

The annual report says the council is “developing appropriate interventions”, which should be implemented soon, that will facilitate the prosecution of schemes that deliberately transgress the law relating to PMBs.

Craig Burton-Durham, the head of the CMS’s legal department who is standing in for the Registrar of Medical Schemes, said this week that members should check with their doctors and other healthcare providers whether a condition is a PMB. If members feel they have
been treated unfairly, they should lodge a complaint with the council.

A recent issue of the CMS’s quarterly publication, CMS News, highlights how members’ lack of knowledge of their rights to the PMBs is preventing them from enjoying these benefits.
Another monthly CMS publication, CMS Script, has been publishing articles aimed at informing you of your PMB rights.

Some of the issues highlighted by both publications are outlined below:

Limits and co-payments that shouldn’t apply CMS News says schemes, in their benefit schedules, often limit benefits for certain broad
conditions without stating that specific conditions within these conditions are PMBs. These broad conditions include oncology, dialysis, organ transplants, prosthesis (internal or external), appliances and specialised radiology.

“Because many schemes neither communicate with nor educate their members, it seems that most members who qualify for PMBs do not realise that the annual limit (for example, R50 000 for renal dialysis) can be applied only to non-PMB conditions, and that the scheme is not allowed to limit the benefit if the treatment is in line with the public sector protocols or practice and obtained from a designated service provider,” CMS News says.

The publication cites the example of a medical scheme that offers a R30 000 benefit for mental illness or psychiatric treatment in-hospital and a R5 000 benefit for out-of-hospital treatment for mental illness and psychiatry. A member of the scheme with bipolar mood disorder was admitted to hospital for medical management of her condition for three weeks.
The claim came to R27 200.

Thereafter, the member needed out-patient psychotherapy. The scheme informed her psychiatrist that she had exceeded her PMB benefits for the year, despite the fact that she still had the R5 000 out-of-hospital benefit.

CMS News says several medical scheme options apply deductibles and/or co-payments to specific procedures or admissions, but these penalties cannot be applied to PMB conditions.

For example, CMS News says, joint replacements are used mostly by older people, who are regarded as high-risk members because their claims can be high.

A co-payment up to R25 000 may be placed on a hip-replacement operation, and a member who fears that he or she may, for example, fracture a hip in a fall may be advised erroneously to join a more expensive option that does not have such a co-payment on joint replacements.

However, CMS News says, a hip fracture is a PMB condition. This means that if a hip replacement is required to treat the fracture, the scheme has to pay for the operation in full, without any co-payments, although it can insist that you have the operation at a designated
service provider.

CMS News says the same principle applies to options with self-payment gaps. These gaps arise when the option offers a medical savings account and an insured benefit (often referred to as an above-threshold benefit) for when you have exhausted your savings
account. If there is a gap between the two, you have to pay for the benefit out of your pocket. This is known as a self-payment gap.

But the cost of the PMBs should not be paid out of your savings account, and you should never be denied a PMB claim because you are in a self-payment gap.

Tests for PMBs must be covered Often, you and your doctor cannot be certain that a condition is a PMB unless you have tests to prove this.

The PMBs cover not only the treatment but also the diagnosis of a PMB condition.

In a recent edition of CMS Script, the CMS says if diagnostic tests or a physical examination confirm you are suffering from a PMB condition, your scheme must pay for the consultation or the tests by, for example, a radiologist or pathologist.

Only if the examination or tests prove that you do not have a PMB can the scheme deny the claim or pay it from your normal benefits or your medical savings account.

If your scheme has already paid for the test or examination from your medical savings account before it has been confirmed that your condition is a PMB, you must ask your scheme to reverse this transaction and to pay the benefit from the scheme’s risk pool.

Similarly, if you paid for the tests yourself, you must ask your scheme to reimburse you.

CMS Script says that if, when you were having diagnostic tests or consultations, you did not use the designated service provider (DSP) your scheme has appointed to provide the PMBs, it must still pay the bill without making you pay a co-payment.

Once the diagnosis of a PMB condition is confirmed, however, the scheme is within its rights to charge you a co-payment if you do not use the DSP.

The newsletter also notes that PMBs are based on the diagnosis of the listed conditions, and it does not matter how you contracted the condition.

Schemes generally exclude cover for cosmetic surgery, the newsletter says, but if you contract septicaemia after cosmetic surgery, this condition is covered because it is a PMB.

Failure to disclose PMB conditions CMS News says many medical schemes list only the 27 common chronic conditions that became chronic conditions in 2004 and do not mention the chronic conditions that are also covered by the 270 PMB conditions.

The publication says examples of chronic medications that are part of the treatment and care of PMB conditions but which are often not listed as such are post-transplant medication, hormone replacement therapy, medication for specific metabolic and endocrine
conditions, anti-coagulant therapy, medication after cardiac surgery, and medication required by quadriplegics and those with valvular heart disease.

CMS News quotes the case of a member who had a heart transplant, for which the scheme paid. However, after the transplant he needed medication to prevent his body from rejecting the heart.

The scheme refused to pay for this chronic medication, arguing that the member needed to belong to the scheme’s most expensive option to enjoy chronic medication after a transplant.

The member also needed consultations, investigations and specific services at regular intervals to monitor his condition after the operation, but was told these would have to paid from his medical savings account.

CMS News says the scheme “got it wrong”, because by law it must provide for these benefits.

The publication says sometimes medical schemes state that an option does not provide benefits for a Caesarean section. However, the PMBs cover the delivery of a baby, and public sector protocols include delivery by Caesarean section where this is clinically

Wrong message
A number of schemes give the impression that their low-cost options do not cover PMBs.
CMS News says the marketing material of some of these schemes go so far as to suggest that all non-hospital treatment and care, even for chronic conditions, either is not covered at all or is covered from a medical savings account.

CMS News cites the case of a scheme that states in its marketing material that it does not provide any out-of-hospital benefits for HIV, other than the funds available in members’ savings accounts.

However, the scheme’s rules correctly provide for out-of-hospital cover for HIV as required in terms of the PMBs.

The incorrect marketing material, CMS News says, would probably put off people who are looking for HIV cover, and in this way the scheme is risk-selecting against prospective members with HIV.

The prescribed minimum benefits (PMBs) cover all the costs of diagnosing, treating and caring for:

270 conditions – mostly life-threatening ones that require treatment in hospital. The PMBs also include urgent care for some non-life-threatening conditions, maternity care and palliative (pain-relieving) care for the terminally ill.
Any emergency medical condition.
27 common chronic conditions.

To contain the cost of providing these benefits, medical schemes are allowed to negotiate rates with particular providers (doctors, hospitals, pharmacists, and so on), and may insist that you use these designated service providers (DSPs) for the diagnosis, treatment and care of PMB conditions.

If you do not use a DSP, a scheme may impose a co-payment. The co-payment should be either the difference between the actual cost of the procedure and what it would have cost at the DSP, or it must be a percentage of the actual cost.

Under certain circumstances, such as in an emergency, you may use the services of a provider other than your scheme’s DSP, and the scheme will still be obliged to pay the bill. 

Your scheme will identify a PMB from a code a service provider should put on your account.
If the service provider does not use the correct ICD-10 code, your scheme will not recognise that the health service you accessed was a PMB. You then need to discuss the matter with your doctor, hospital or pharmacist.

Not all cancers are prescribed minimum benefits (PMBs), the February 2009 edition of CMS Script says.

The publication says there are two kinds of cancers:

Cancers that affect non-solid organs and systems; and Cancers of the solid organs.

Many cancers of the non-solid organs and systems are PMBs regardless of whether or not they are regarded as treatable. Examples of these cancers are acute and chronic leukaemia, lymphomas and multiple myeloma.

A cancer that affects a solid organ is a PMB only if it is “treatable”. A cancer is regarded as”treatable” when:

It affects only the organ of origin;
There is no evidence that it has spread to other organs in the body:
It has not caused incurable damage to the organ in which it originated or to any other life- supporting organ; and
There is scientific evidence that more than 10 percent of people with a similar cancer survive on treatment for at least five years.

If the cancer is not a PMB, your scheme’s usual oncology benefits will apply. Schemes often have a limit on oncology benefits, such as R60 000 or R200 000 or R400 000. Pathology, radiology, radiotherapy, chemotherapy and surgery related to the cancer may all deplete this benefit.

Treatment protocols
Your scheme may have certain protocols in terms of which it pays for oncology.

In the case of a cancer that is a PMB, your medical scheme may also have protocols that state for which treatment it will or will not pay, but the minimum standard must be at least what you would receive if you were treated for cancer in a state hospital.

If your doctor wants you to use a medicine that is not available from state healthcare facilities, you may have to foot the bill yourself, or the scheme may reimburse you only the amount it would have paid had you used the medicine dispensed by state facilities or an
equally or more effective medicine the scheme has chosen to cover.

CMS Script says you should also remember that you often need to begin with the first line of treatment, and only when that fails can you move on to the next line of treatment. Your medical scheme may ask for evidence that the first line of treatment has failed before it approves the next line of treatment.

Often, you need to obtain pre-authorisation for oncology benefits, and your doctor may need to submit certain information to your scheme about your cancer and the stage of your illness.

Even if your cancer does qualify as a PMB, if the disease progresses and, for example, becomes an untreatable cancer of the solid organ or organs, you may no longer qualify for benefits for treatment in terms of the PMBs. You will then only qualify for the medical
scheme’s oncology benefits, if the scheme option has any, or palliative care.

To qualify for PMB cover, your doctor may also have to submit a treatment plan.

If you have treatable cancer of the colon and part of your colon is removed, and it becomes necessary for you to use stoma or colostomy bags, these should also be covered as part of the PMBs.

The scheme can take the cost of the bags out of your “appliance” benefit, but once this is exhausted, the scheme must continue to pay for them.

Published on the web by Personal Finance on September 19, 2009.