CMS takes Keyhealth to task for not paying out for PMBs

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The Council for Medical Schemes (CMS) says it’s “concerning” that Keyhealth Medical Scheme denied a member prescribed minimum benefits (PMBs) for an overactive thyroid on the basis that she needed to develop a “thyroid storm”, which is a medical emergency, before she could qualify for PMBs. Hyperthyroidism is a PMB condition, the council says. “This patient’s condition cannot validly be considered not to be a PMB just because her life is not in immediate danger,” the council’s clinical review committee says in a ruling against Keyhealth handed down earlier this year.

Business Day reports that the ruling stems from a complaint lodged by healthcare rights activist Angela Drescher on behalf of a member who Drescher says was treated unfairly by Keyhealth. The scheme at first rejected the member’s claims, saying her condition was not a PMB condition and not covered in terms of her benefit option.

The ruling says that in October 2018, the member consulted her doctor as she was experiencing severely itchy skin. Her doctor ordered blood tests to confirm a diagnosis. He diagnosed kidney problems and prescribed medication that provided no relief from the symptoms, so she sought a second opinion. A week later, a second doctor diagnosed her with hyperthyroidism (an overactive thyroid) and thyrotoxicosis with goitre. The diagnosis was confirmed by blood test results.

In a letter of motivation to the scheme, the doctor stated that the patient’s conditions were serious and could be life threatening. He also set out the treatment she may require and prescribed medication. A month later, the patient consulted a surgeon, who confirmed the diagnosis of hyperthyroidism and submitted a letter of motivation to the scheme stating his findings and treatment options.

According to the report, the ruling says the member made several attempts to claim for the diagnostic tests, the treatment and care as well as authorisation for further tests and future treatment. One of her consultations was with a specialist who is not one of the scheme’s designated service providers (DSPs) because the DSP closest to her home, in the Nelspruit area, is more than 200km away. After the member paid the account in full, the scheme failed to reimburse her in full.

After the complaint was lodged with the council, Keyhealth conceded that it had been incorrect and that hyperthyroidism was a PMB, the ruling says. The scheme said it did not know why the member had raised the non-payment of claims, contending that all disputed claims had been paid since the council intervened. But Drescher and the member said this wasn’t so and that some claims had been paid from the wrong benefits, namely the member’s medical savings account.

The report says in terms of the ruling, the scheme must fund diagnostic tests, care and treatment for the member’s PMB condition in line with PMB regulations and as per the clinical opinion by the CMS’s review committee. The scheme must also ensure that future tests, treatment and consultations for the condition are paid in line with PMB regulations, taking into consideration the level of care offered by the state, the ruling says.

The ruling notes that the scheme may payPMB claims from any day-to-day benefit the scheme provides as part of the risk benefits. But when this benefit is depleted the scheme must continue to pay yPMB claims. The scheme may never, however, pay PMB claims from the member’s medical savings account, as this is prohibited in terms of regulations under the Medical Schemes Act. If any PMB claim was paid from the savings benefit, the scheme must reverse such payment and process it from the correct benefit, the ruling says.

According to the report, the ruling ordered Keyhealth to reimburse the member for claims already paid by her for the PMB condition, which was a result of the scheme’s incorrect processing or interpretation of the claims, the council says. Lastly, the ruling ordered the scheme to pay claims for the non-DSP specialists in full if there was no DSP within reasonable proximity from the member’s place of residence.

Business Day report

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