PMB claims: try, try again

PF IOL 10Nov PMBs update2 Colin Daniel You may have to struggle to get your medical scheme to pay a claim for a prescribed minimum benefit.

Medical schemes are obliged to pay for treatments defined as prescribed minimum benefits (PMBs) to ensure that you will always have cover for essential health care.

But the system isn’t perfect, and your medical scheme may reject a PMB claim that it should pay or it may dispute a claim for an alternative treatment for a PMB condition when the standard treatment fails or is unsuitable for you.

If you want to avoid out-of-pocket medical expenses or being denied treatment, make sure you know your rights when it comes to PMB claims.

PMBs – benefits that schemes are obliged by law to provide – cover all life-threatening emergencies, 270 conditions that, if left untreated, would severely affect your quality of life, and 25 common chronic conditions.

The first of the three case studies on this page highlights a problem at least one scheme member has encountered with enforcing her rights to PMB benefits, and emphasises your right to alternative treatment if the treatment provided by your scheme fails or is not suitable for you.

The lesson in the second case study is that if you or a family member have any kind of life-threatening emergency, your medical treatment should be covered by the PMBs, regardless of which doctors or hospitals you use.

If doctors charge more than the scheme rates, remember that your medical scheme is obliged to pay these bills in full if they relate to a life-threatening emergency.

If your scheme does not pay any of the bills in full, query these with your scheme’s administrator. If you do not receive a satisfactory response from the call centre, address your query to the principal officer of the scheme.

When it comes to healthcare services for PMB conditions that are not emergencies, remember that your scheme may have entered into payment arrangements with various doctors and hospitals, and your PMB treatment will be covered in full only if you use the provider with whom your scheme has contracted.

Both the second case study and the third one reveal that claims that should be paid may initially be rejected by your scheme, and it is up to you to query them with the administrator of your scheme.

The third case study highlights how claims for pathology tests may be paid incorrectly from your medical savings account because your medical scheme is unable to identify them as PMB claims.

CASE 1. SCHEME WON’T PAY FOR ALTERNATIVE TREATMENT

Disputes can arise over your scheme’s obligation to pay claims, even when they are for conditions that it is required by law to cover, and resolving these disputes can take a very long time. In the interim, you may be left with inadequate treatment. This is the painful lesson a Discovery Health Medical Scheme (DHMS) member says she has learnt.

Sheila van Straten has rheumatoid arthritis, an auto-immune disease that leads to painful inflammation of the joints and surrounding tissues.

Rheumatoid arthritis is a prescribed minimum benefit (PMB) condition, and DHMS initially paid for Van Straten’s treatment, but when the so-called baseline treatment failed, her doctor recommended a biologic, Enbrel, that costs R10 000 a month. (A biologic is a genetically engineered medicine.)

DHMS refused to pay, saying the biologic is not included in the treatment provided for rheumatoid arthritis in the PMB regulations, despite the fact that her doctor wrote a motivation for the biologic, saying conservative treatments were not helping and Van Straten could not tolerate other medicines.

Van Straten’s doctor made the recommendation in January this year, and in September she obtained a ruling from the Council for Medical Schemes ordering the scheme to pay for biologic.

However, DHMS is still not paying for the Enbrel and plans to appeal against the council’s ruling.

The Council for Medical Schemes says the appeal will be heard next month.

In the meantime, to manage the cost of her treatment, Van Straten is taking a lower dose of Enbrel than her doctor recommends. She says this has left her in constant chronic pain, fatigued and struggling to work.

While the lengthy dispute plays out, the regulations that are designed to protect Van Straten by ensuring her scheme is obliged to pay for certain conditions appear to have failed her.

Dr Jonathan Broomberg, chief executive officer of Discovery Health, the administrator of DHMS, says the scheme disagrees with the council’s ruling and believes it cannot be expected to pay for the biologic, because it is expensive. DHMS will consider funding an alternative treatment that is cost-effective, but the scheme cannot recommend such treatment, he says.

The Medical Schemes Act allows schemes to develop treatment plans for a PMB as long as that treatment is equal to or better than the minimum treatment standards for each PMB condition as provided for in the law. Frequently, reference is made to the treatment provided in state healthcare facilities.

However, the ruling that ordered DHMS to pay for Van Straten’s Enbrel points out that the regulations also state that if you have a poor response to, or will come to harm following, the treatment plan a scheme provides for a PMB condition, the scheme is obliged to provide an appropriate exception.

The ruling issued by the Registrar of Medical Schemes, Dr Monwabisi Gantsho, says DHMS was asked to explain its clinical protocol where the standard treatment plan is ineffective.

The registrar’s office had, however, not received a response and DHMS is therefore obliged to make an exception for Van Straten, the ruling says.

Broomberg says the council’s ruling has not taken into account the extremely high cost of the drugs, that they are demonstrably not cost-effective, and that funding these drugs for members on all DHMS’s plans would be financially unsustainable for any medical scheme.

He says making all biologics available to members on all plans would cost DHMS about R60 million a year.

When Van Straten’s doctor recommended the biologic on January 24 this year, Van Straten asked DHMS if she could upgrade from her Coastal Core option to an option that has a benefit for specialty medicines. The scheme declined permission.

Van Straten then applied to the scheme for an ex gratia payment for her treatment until the end of this year, but this was also denied.

Broomberg says because a ruling by the council is suspended while it is under appeal, it would not be appropriate for DHMS to fund biologics for Van Straten while the matter remains under appeal.

Van Straten says she is disgusted by Discovery’s actions, because while “they are prolonging the process, I am living in constant chronic pain and agony, and they simply do not care”.

CASE 2. EMERGENCY EXPENSES UNDER-PAID

Mrs D, a pensioner, was grateful that her husband’s scheme paid many of his substantial medical bills when he collapsed from internal bleeding, suffered two cardiac arrests and was admitted to intensive care.

Mr D was in an intensive care unit (ICU) for a week before he passed away from organ failure. The medical bills were numerous and high, including one for more than R121 000 for the hospital.

The scheme settled many of them, but Mrs D was alarmed that there were still thousands of rands outstanding on some of the bills.

* The doctor who treated Mr D in ICU, for example, charged R26 794. Mr D’s scheme, LA Health, initially paid R13 199.

* The anaesthetist charged R8 050. The scheme initially paid R3 358.

* The radiologists charged R11 138. The scheme initially paid none of this bill.

* The suppliers of blood charged R4 379. The scheme initially rejected this claim.

* The paramedics charged R2 684. The scheme initially rejected this claim.

Fortunately, the treating doctor attached a note to Mr D’s claim stating that his treatment fell within the prescribed minimum benefits (PMBs) and that his scheme should pay his claims in full.

Mrs D’s family queried the claims with LA Health, and eventually all the outstanding amounts were settled, sometimes after further information was obtained from the doctors or healthcare providers and sometimes after the diagnostic codes (ICD10 codes) were amended. Had Mrs D not queried the claims, the outstanding bills could have ended up as claims against Mr D’s estate and ultimately reduced Mrs D’s inheritance.

Mrs D’s case illustrates how you, as a member of a medical scheme, need to be informed about your PMB rights, and must insist that your rights are enforced. You should not assume that your medical scheme will recognise claims as PMBs, even when it appears obvious that the claims are all related to an emergency.

Dr Jonathan Broomberg, chief executive of Discovery Health, which administers LA Health, says, in many cases, claims submitted by healthcare providers to schemes do not contain the correct diagnostic information required to recognise the relevant PMB condition, and schemes’ automated payment systems therefore cannot recognise these claims as PMBs.

Broomberg says claims from multiple providers – including hospitals, doctors and pathology laboratories – are each read as a separate claim, and if the procedure codes and diagnostic (or ICD10) codes are incomplete, the claims cannot be identified as PMBs and paid as such.

CASE 3. CLAIMS PAID FROM SAVINGS ACCOUNT

A member of Momentum Health, Mr E, noticed that his claim for a consultation, and blood and urine tests for hypertension (high blood pressure) and high cholesterol were not paid by his scheme but from his medical savings account.

Both these conditions are prescribed minimum benefits (PMBs), and claims for PMB conditions may, by law, not be paid from your medical savings account.

Mr E had registered his conditions with Momentum Health. He received a chronic condition treatment plan that outlined the various consultations and tests to which he was entitled.

On querying how the claim had been paid, Mr E received a reply from the scheme to the effect that “the tests done do not form part of the chronic treatment plan”.

When Personal Finance took up Mr E’s case with Momentum Health, the scheme said it would reprocess the claims.

Damian McHugh, Momentum Health’s head of marketing and sales, says pathology laboratories do not include diagnostic codes (ICD10 codes) on their claims, and they are not obliged to do so in terms of the Medical Schemes Act.

As a result, McHugh says, the scheme cannot automatically identify that a pathology claim is linked to a member’s registered chronic condition.

Only if a member queries the non-payment of the claim, or the payment of the claim from a medical savings account, can the claim be reprocessed and paid as a PMB, McHugh says.

Momentum Health said Mr E’s initial query was “not dealt with appropriately”.

McHugh also pointed out that a consultation Mr E had with his general practitioner had been assigned the incorrect ICD10 code and was therefore also incorrectly paid from Mr E’s savings account.

FUNDING HIGH-COST MEDICINES ‘IS A CHALLENGE’

Managing expenditure on speciality and high-cost drugs is a challenge facing medical schemes worldwide, Dr Jonathan Broomberg, chief executive of Discovery Health, says.

The rate at which these high-cost drugs are being developed and the increase in the number of medical scheme members being treated with them are contributing to the high costs schemes are experiencing, he says.

In 2010, Discovery Health Medical Scheme (DHMS) spent a total of R23.3 billion on health care, of which 20.6 percent, or R4.8 billion, was on medicines, Broomberg says. Of the R4.8 billion, R603.1 million went towards 210 high-cost drugs (five percent of all drugs funded by DHMS for 0.6 percent of the scheme’s membership).

Projections show that, by 2016, DHMS will spend about R6.3 billion on drugs, of which just under half, R3 billion, will be on providing high-cost drugs for 1.5 percent of the scheme’s total membership, Broomberg says.

Funding high-cost drugs, therefore, has a significant financial impact on medical schemes. This has potentially far-reaching consequences for not only the medical schemes industry, but the South African healthcare system in general, he says.

HELP WITH YOUR COMPLAINTS

If you have a complaint about your medical scheme not paying for a prescribed minimum benefit (PMB), you can call the Council for Medical Schemes at 0861 123 267. Fax complaints to 012 431 0608 or email to [email protected]

The list of PMBs is available on the council’s website, www.medicalschemes.com


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