Fraud and abuse are being practised by medical schemes that are failing to pay out prescribed minimum benefits (PMB) to members, forcing consumers to absorb around R38bn in co-payments, some of which they should not be paying.
Yet in the meantime, said Mark Human, chief executive of Medicheck at the Board of Healthcare Funders conference in Cape Town last week, the medical schemes and administrators are sounding the alarm over fraud, waste and abuse in the industry.
By law, medical schemes are bound to pay for costs related to 271 conditions and 26 chronic conditions that are classified as PMBs, reports Daily Maverick. Under the Medical Schemes Act, these include diseases like TB and cancer, while chronic conditions classified under PMBs include asthma, epilepsy and hypertension/high blood pressure.
Medical expenses for these conditions are meant to be paid out from the scheme’s combined risk pool and not from day-to-day benefits or a member’s medical savings account.
The key provisions around the funding of PMBs by the medical scheme as per the Medical Schemes Act include:
• Benefit conditions must be paid in full, as per the invoice submitted by your healthcare provider like the doctor, a specialist, or a hospital.
• Your scheme is not allowed to use your personal medical savings account to pay for benefit conditions.
• Your scheme is entitled to nominate a designated service provider such as a doctor, pharmacy, or hospital as the first-choice provider when you need treatment or care for the benefit’s condition. Read the fine print on your medical scheme documents. If a DSP is provided for under the option you choose, and you then choose to use a doctor or hospital that is not a DSP, you may end up having to pay a hefty co-payment. If it is an emergency and you have no choice but to use the nearest provider, the scheme may make an exception for this but will request proof that it was, in fact, a medical emergency.
• You usually have to register a chronic PMB condition with your medical scheme before your costs are paid as a PMB benefit.
Jeremy Yatt, principal officer of Fedhealth, says members would typically have to submit information such as the name of their doctor, his/her practice number, the correct diagnosis or ICD-10 code, the name of the medication required, its strength and directions for use.
Hyman says some of the problems around the non-payment of PMBs include doctors not providing proper referrals or diagnostic codes (ICD-10 codes). “For example, doctors should be writing down ICD-10 codes next to line items on their prescriptions, particularly when that information is needed by pharmacists or pathologists,” he says.
Pharmacists may not make a medical diagnosis or assign ICD-10 codes to a claim, which means members experience severe difficulty in getting their scripts funded correctly if a default code is used by the pharmacist.
Daily Maverick article – Medical scheme members hobbled by R38-billion pothole (Open access)
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