The Medical Schemes Act is silent on the costs that schemes must cover when “an emergency” turns out to be a “false alarm” or a “lucky escape”, medical scheme representatives say.

Jeremy Yatt, the principal officer of Fedhealth, says the Act does not address whether medical schemes are obliged to pay for the diagnosis of an emergency that is not a prescribed minimum benefit (PMB).

Yatt says he does not believe the Act supports the opinion of the Council for Medical Schemes (CMS) in the March edition of CMScript (a publication aimed at members) that schemes should pay for the treatment of conditions provisionally diagnosed as an emergency until it is confirmed that they are not.

He says it is not right for the CMS to “rule by circular”, or CMScript, when interpreting the Medical Schemes Act.

As a result of the uncertainty over how the PMB regulations should be interpreted with regard to liability for emergency treatment, Fedhealth boosted its trauma benefit to provide that any physical injury caused by an external force that requires immediate medical attention will be paid from a member’s risk benefits. “This benefit was introduced to reassure our members that trauma injuries, such as dog bites, cuts and breaks, would be covered by the scheme,” he says.

Dr Bettina Taylor, the head of the health policy unit at Medscheme, which administers a number of schemes, says the accurate and efficient identification of emergency PMB claims is a challenge for administrators.

“In terms of the regulations under the Medical Schemes Act, an emergency medical condition is ‘the sudden and, at the time, unexpected onset of a health condition that requires immediate medical or surgical treatment, where failure to provide medical or surgical treatment would result in serious impairment to bodily functions, or serious dysfunction of a bodily organ or part, or would place the person’s life in serious jeopardy’,” she says.

She says Mathew du Toit’s case does not seem to meet these requirements, because treatment for an emergency condition was ruled out after diagnostic tests had been performed.

However, she acknowledges that the PMB code of conduct states that schemes must pay for treating and diagnosing a condition that has been provisionally diagnosed as an emergency until it has been established that the condition is not, in fact, an emergency.


Code of conduct

But what is the legal status of the code of conduct?

The regulations under the Medical Schemes Act state that, every two years, there should be a review of the PMBs by the Department of Health, in consultation with the CMS, the provincial health departments, consumer representatives and other stakeholders.

However, a review has not been completed since the regulations were implemented in 2002.

As a result, in 2010 the CMS and the Department of Health called a meeting of medical scheme representatives, administrators, doctors’ associations, consumer groups and the Health Professions Council of South Africa and hammered out the code of conduct.

Dr Elsabe Conradie, the head of stakeholder relations at the CMS, says the draft code was published and finalised after all stakeholders had been invited to comment on it. The areas where final decisions could not be reached were indicated in the final document, she says.

Conradie acknowledges that the guidelines “lack legal status”, and in the event of a conflict between them and the PMB regulations, “the definitions contained in the regulations will prevail”.

Healthcare providers, such as doctors, also signed the code, but not all of them make sure their accounts include diagonistic and treatment codes that indicate that a condition was an emergency.

The council and the Medical Schemes Act have no authority over healthcare providers.

Confusingly, after the code was signed, the CMS released a CMScript in 2012 with the title “It’s an emergency only if you need immediate treatment”. The publication stated “if you are not treated for your condition, and only tests are conducted, your medical scheme does not necessarily need to cover your condition, because tests are diagnostic measures which are not covered by the definition of an emergency”.

This view was updated in the CMScript issued in March this year, which said that schemes should “cover the costs from the PMB benefits up to the stage where a non-PMB diagnosis was made”.

Rajesh Patel, the head of benefit and risk at the Board of Healthcare Funders, which represents schemes and their administrators, says the PMB regulations should be reviewed so that they define what is meant by “essential services”. The current legislation lists “diagnoses with vague treatment descriptors”.

“The Medical Schemes Act and regulations do provide for the Council for Medical Schemes to issue guides, but these guides cannot be prescriptive. The fall-back is the regulations, appeal processes and courts, which can finally adjudicate on what benefit is intended in the regulations,” he says.

Commenting on the financial impact of the obligations imposed by the code of conduct, Dr Jonathan Broomberg, the chief executive of Discovery Health, says, “the very design of the PMBs lends itself to complexity and onerous funding requirements. This is evident in the difficulties that all roleplayers have in understanding and implementing the requirements of the Act and the ongoing industry-wide disputes on the matter.”


Risks of downgrading

Asked how Profmed would have dealt with Mathew du Toit’s claim, principal officer Graham Anderson says the scheme would have classified the incident as an emergency until proved otherwise.

He says schemes can face problems when processing PMB claims from members who have downgraded their cover, because lower-cost options typically do not provide cover for diagnostic tests not conducted in a hospital, unless the condition is subsequently shown to be a PMB.

He says doctors are increasingly admitting patients to hospital for tests under the guise of an emergency, because they want to help patients who do not have sufficient funds. “We have to scrutinise every medical claim that uses emergency coding to ensure that it is, in fact, an emergency admission,” Anderson says.