A company that helps medical scheme members when a claim is short paid or not paid at all says many schemes are underpaying for the prescribed minimum benefits (PMBs), some to an alarming degree. 

One of the schemes named in its report, Discovery Health Medical Scheme (DHMS), has fired back, saying the company’s conclusions are misleading and are based on skewed research.

The PMBs are benefits that medical schemes are obliged to provide in the event of a life-threatening condition or emergency. The list of recognised PMB conditions is available on
 the website of the Council for Medical Schemes (CMS),
 www.medicalschemes.com.

Med ClaimAssist, a division of Constantia Insurance Company, has intervened in 8 433 claims and collectively saved clients more than R16 million. In a recent study it conducted, since March this year it found 239 instances of non-payment in PMB emergency cases.

As these were PMB emergencies, the schemes were responsible for paying the claims in full, according to Dr David Green, the managing director of Med ClaimAssist.

“All the codes submitted on the claims were checked by our team of claims specialists, and where there were errors and other issues with the coding, these were clarified with the doctor (and if appropriate, corrected) prior to approaching the medical scheme.

“All of these claims should have been paid by the scheme involved.

“We have approached the scheme through the available channels, with patient consent, escalated the query within the scheme, and basically persevered in our query, and the scheme has still refused to pay the claim as a PMB,” Green says. 

Med ClaimAssist says the five worst-performing schemes, by average percentage paid out to members, were:

  • LA Health Medical Aid (administered by Discovery): 17.38%;
  • Quantum Medical Aid Society: 19.48%;
  • Bankmed (administered by Discovery): 28.85%;
  • TFG Medical Aid Scheme: 34.42%; and
  • MedShield Medical Aid: 34.83%.

In rand-value terms, DHMS short paid the most – paying only 39.79% of what it should have, says Med ClaimAssist.

“Considering the significant amount members pay to their medical schemes every month, it is shocking to think they could still be held responsible for more than 80% of payments, even in PMB emergency cases,” Green says.

He says there are three broad categories of mistakes leading to the non-payment or short payment of claims for PMB conditions:

  1. Errors on the patient’s side: for example, the medical scheme may require that health services are accessed through a network of providers known as designated service providers (DSPs). If the patient accesses services from a non-DSP provider when they could have gone to a DSP, the medical scheme may pay short or not pay the bill at all. However, this does not apply in the case of emergencies.
  2. The provider may make an error: this commonly occurs when the provider submits an inaccurate or incomplete diagnosis or procedure code on the claim to the scheme.
  3. The medical scheme may make an error in processing the claim. 

“It is never easy identifying the root cause of these issues, as the complex sets of rules, benefits and codes make it almost impossible to ascertain,” Green says. He says Med ClaimAssist uses a “claims engine” to identify where exactly the problem lies, after which it approaches the source, whether a medical service provider or scheme, to get the claim paid.

Discovery’s response

DHMS says it strongly disagrees with the views and conclusions arising from the Med ClaimAssist study. The scheme’s principal officer, Dr Nozipho Sangweni, says DHMS is fully compliant with the Medical Schemes Act, its regulations and the scheme’s rules. 

Sangweni says there are several problems with the data and methods used by Med ClaimAssist, and this has led to distorted results and misleading conclusions. The key problems are:

  • It is based on a very small sample size of 239 cases across all medical schemes, and only 130 DHMS cases.
  • The sample is extremely biased, Sangweni says, because the cases are specifically those in which there is a dispute with the medical scheme, on which Med ClaimAssist has been asked to assist and has failed to get resolution. “The sample therefore entirely omits all PMB claims that have been settled without any issue arising, as well as all the PMB claims that Med ClaimAssist has resolved with the schemes concerned,” she says.
  • Although DHMS has been provided with the underlying data, Sangweni says, “it has been anonymised, and we are thus unable to analyse the specifics of each claim, and to comment on the reasons why the claims have not been covered in full”.

She says: “It is simply not true that DHMS pays out a small proportion of PMB claims. We have analysed every PMB claim received by DHMS during 2017, with the following results: the scheme paid approximately R26 billion for PMBs. The vast majority were paid in full, while others were partially paid [for reasons given above]. On average, for every rand claimed for PMB treatments, DHMS paid out 93 cents, more than double the proportion cited by Med ClaimAssist.

“The study argues that these claims are all for PMB emergencies. DHMS can confirm it pays 100% of confirmed emergency claims in full. There are naturally some claims where the emergency nature of the situation might be disputed, and Med ClaimAssist might believe that some claims are PMB emergencies when they are actually not. As we have not been provided with identified claims data, we are unable to analyse each of the cases to provide specific comment,” Sangweni says.

If you disagree with the amount paid out by your medical scheme, you can lodge a formal dispute with your scheme or lay a complaint with the CMS.

Sangweni says that in 2017, 52 cases were heard by the DHMS disputes committee, of which seven related to PMBs, and 763 CMS complaints were lodged. “This means that 0.001% of the 53 million DHMS claims processed in 2017 resulted in a CMS complaint. These are very low in absolute terms and very low compared to other medical schemes. DHMS does not feature on the CMS list of medical schemes with the highest complaints per 1 000 beneficiaries,” she says.

DHMS’s full response is available here.

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