CMS must consolidate SAMA case over specialists’ billing

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The Competition Tribunal has ordered the Council for Medical Schemes (CMS) to submit further details and consolidate its case against the South African Medical Association (SAMA) in a long battle over how specialists bill patients, reports Business Day.

The report says the matter potentially has far-reaching implications for the way medical schemes reimburse patients, as SAMA is the biggest doctor organisation and holds sway across the industry.

The dispute between the parties dates back to 2013 and centres on the CMS’s allegation that SAMA has engaged in a prohibited horizontal practice by endorsing the billing practices of the South African Paediatric Association (Sapa) and the Society for Cardiothoracic Surgeons in SA (SOCTSA), thus breaching the Competition Act.

These associations use extra billing codes that are not included in the National Health Reference Price List (NHRPL), published by the CMS more than 10 years ago. While the NHRPL codes and prices are not legally binding, many medical schemes use them to set reimbursement levels for patients and will not pay for codes that are not in the NHRPL. Doctors say the NHRPL codes are outdated and fail to reflect current practice.

The CMS alleged SAMA’s 2009 tariffs allowed paediatricians to bill an extra 50% above the NHRPL rate for new-born babies that needed intensive care. It also complained about the 2010 billing guidelines published by SOCTSA.

SAMA asked the tribunal for an order in March to dismiss the council’s complaints or force it to provide more details of the allegations of price-fixing it made against the associations.
The report says the tribunal dismissed SAMA’s application to have the matter dismissed, but gave the CMS 20 days to consolidate their pleadings in connection with the two complaints it lodged in July 2013. “The (2013) referrals have… evolved… and such evolution has given rise to confusions and contradictions,” the tribunal said.

It ordered the CMS to elaborate on the binding nature of Sama’s publications, why it is important for SAMA to publish them, and how it achieves compliance by paediatric specialists. “CMS needs to outline what mechanisms, if any, are used by SAMA to punish noncompliance,” the tribunal said.

CMS spokesperson Elsabe Conradie said in the report that SAMA had requested another statement, which it was working on.

Business Day report

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