Bonitas members have complained about unresolved queries and hospital authorisations after the administrative switchover of Bonitas medical scheme members to Momentum last week. But Bonitas has blamed Medscheme’s backlog for the issues – which the latter has roundly rejected, reports News24.
Bonitas, which has 750 000 beneficiaries, had attributed members’ woes to previous administrator Medscheme, which in turn has pointed the finger at the new service providers, Momentum Health and Private Health Administrators (PHA).
Medscheme and Bonitas are already clashing swords, as Medscheme took Bonitas to court last year over its planned change in administrators, alleging tender irregularities.
Business Day reports that last week, dozens of Bonitas members aired their complaints on social media, blasting delays and a lack of response to authorisation requests after the new service providers took over on 1 June.
But Bonitas principal officer Lee Callakoppen blamed Medscheme for the mess, saying it had handed over an unexpected backlog of more than 10 000 outstanding matters: these included queries about claims, authorisations that had not been granted and savings refunds, among other issues, said Bonitas. Anomalies in historical member data compound the challenges.
PHA CEO Ayanda Mbuli said the company received hospital authorisation data files later than agreed and an unexpectedly large volume of unresolved matters. PHA, which provides managed care and hospital authorisation services, received more than 7 000 open authorisation and case management items on 30 May, with a further 7 000-plus cases handed over on 1 June, she said.
For a scheme the size of Bonitas, PHA would normally expect 1 700 such queries a day, she added.
However, Medscheme has hit back, saying it warned Bonitas against opting for a clean break, with a final service cut off on 29 May. “Typically a proper wind-down would involve both parties working in conjunction to resolve queries,” it said.
Medscheme said it had provided daily query volume updates to Bonitas and the new service providers from 25-29 May to allow for adequate planning. There was no backlog, and the numbers Bonitas referred to were normal business volumes, it said.
It added that it was Bonitas’ decision to forgo the traditional phased approach to transitioning to new service providers that caused the disruptions.
“As anticipated and advised early on by Medscheme, this decision has regrettably manifested in the current risks faced by Bonitas members in obtaining authorisations for surgeries and other healthcare services.
“The challenges reported … highlight again the importance of placing member interests at the centre of major operational decisions.”
Bonitas has also blamed healthcare providers for not switching over to its new digital platform in time.
The blame game comes as both parties prepare for a court battle over whether there were irregularities when Bonitas left Medscheme for Momentum Health. The dispute was meant to be heard in court on 9 and 10 June, but the matter has since been postponed due to legal complexities. The parties are awaiting a new hearing date.
Teething
Momentum Health chief marketing officer Damian McHugh said switching a scheme the size of Bonitas from one administrator to another is a huge undertaking, and “teething problems” are to be expected. Momentum Health has 18 client schemes, including Bonitas, covering a total of 3.96m lives.
Medscheme, the Bonitas administrator for 43 years, took legal action against the scheme over its decision to change service providers last year, asking the court to interdict Bonitas from implementing its contracts with Momentum Health and PHA pending the outcome of a forensic investigation by the Council for Medical Schemes (CMS) into an administration contract Bonitas previously awarded PHA for its low-income option Boncap.
The CMS has encouraged schemes to review long-standing administration contracts. In a recent industry circular, it expressed concern about the risks of “evergreen” deals. It said such contracts might not be regularly assessed to ensure they offered value for money, weakened scheme governance because administrators might have undue influence over the board of trustees and potentially restricted new market entrants.
CMS spokesperson Stephen Monamodi said the regulator does not have a view on the situation at Bonitas, as it does not know the extent, nature or cause of the problems. “We have reached out to Bonitas to obtain the details,” he said.
Business Day article – Bonitas blames Medscheme for medical scheme backlog (Restricted access)
News24 article – It’s all Bonitas’ fault, says ousted administrator Medscheme (Restricted access)
See more from MedicalBrief archives:
Chaos and bottlenecks in Bonitas-Momentum changeover
Bonitas-Medscheme row threatens jobs – Sanlam CEO