Colin Daniel
Colin Daniel

PMB pitfalls to avoid

By Laura du Preez Time of article published May 25, 2014

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Members of medical schemes are becoming more informed about the prescribed minimum benefits (PMBs), and doctors can help to facilitate PMB claims by informing members when their condition is a PMB, but a lack of knowledge can result in your being denied benefits to which you are entitled.

Some medical practitioners print on their accounts messages such as, “This treatment falls within the PMBs and should be settled by your scheme in full”, but when bills remain unpaid by schemes, practitioners turn on you, the member, saying the payment of the bill is your responsibility.

Here are some common problems you may need to navigate to receive the benefits to which you are entitled.

1. The condition that seems to be a PMB, but isn’t

Members and their doctors often have an idea that a condition is a PMB, but in the fine print it turns out that the condition is not a PMB.

For example, high blood pressure or hypertension is a PMB, but a member of a large open scheme had her claim for treatment of a mild form of this condition rejected, because, according to her scheme, the dose of medication prescribed was too low to meet the criteria to qualify as a PMB.

Recently, a doctor assured a patient that the removal of suspected basal cell carcinoma would be covered by the PMBs, but the claim was not paid in full. On confronting the scheme, the member was told the scheme needed to see the histology report, and only if the cells removed were of a particular depth, would their removal qualify as treatment in terms of the PMBs.

2. The diagnostic test without the correct code

The diagnosis of a PMB condition should be covered in full, but when a member is sent for a diagnostic test, the diagnosis is often not immediately obvious (see “Paying for the diagnosis of a PMB”, below), so the pathologist or radiologist uses a “z” code to indicate an undiagnosed condition. Only when the doctor reads the test results is a diagnosis confirmed. In the meantime, the bill for the test is submitted to your scheme and not paid as a PMB, because the “z” ICD10 code is not recognised as one covered by the PMBs. (ICD stands for the “International Statistical Classification of Diseases and Health-related Problems”.)

Members can resubmit these claims, but the claim may have to be accompanied by a letter from the treating doctor, and it may be difficult to obtain a letter from a busy healthcare practitioner.

Pathologists and radiologists will not amend the codes and resubmit the claim on a member’s instructions.

Members who regularly require diagnostic tests, scans or other treatment for a chronic condition must ensure the forms are completed by their doctors and that the correct ICD10 codes are supplied.

3. You are referred to a doctor who is not a designated service provider

To contain the costs of PMBs, medical schemes may appoint designated service providers that members are expected to use if they want to be covered in full. This may include a network of specialists. But if your general practitioner (GP) refers you to a specialist who is not a member of that network, you are faced with the difficult decision of following the GP’s recommendation and paying extra, or choosing a specialist in the network who is not known to your GP.

4. The emergency that isn’t an emergency

PMBs cover all medical emergencies, but problems arise when what appeared to be an emergency turns out, on diagnosis, to be a non-emergency. Members are finding that in these cases schemes are not paying for consultations in emergency rooms or for tests performed to establish whether or not the emergency was a life-threatening condition.

The Council for Medical Schemes Appeal Committee confirmed in a 2011 case that a large open scheme did not have to pay for two electrocardiogram tests performed on a member who experienced chest pains after a golf game, because the tests proved that he did not have a heart problem.

The Appeal Committee said the scheme would have been obliged to pay only for any treatment that the man received before the diagnosis was made.

Members or their dependants sent to an emergency room are typically in no condition, nor do they have the knowledge, to dispute the need to be sent there. Who would question a retirement village nurse who calls an ambulance for an elderly resident suffering from chest pains, or think twice about advice from a school to take a child who has fallen from a playground jungle gym and injured his head to the emergency room?

Some medical schemes have introduced a casualty benefit to cover tests and treatment in an emergency room, regardless of the diagnosis, from the scheme’s benefits, and to do so so that they do not risk depleting a member’s savings account.

5. Emergency treatment for which doctors charge more than scheme rates

Despite the fact that a condition may have been an emergency – which should be covered by the PMBs regardless of what the practitioner charges – medical scheme administrators do not always recognise claims as relating to an emergency and may pay claims only up to the scheme rate, unless challenged.

When a member suffered internal bleeding and cardiac arrest, and was admitted to intensive care for a week before dying as a result of major organ failure, a restricted medical scheme paid all the hospital bills, which came to about R121 000, but only some of the R53 045 in claims submitted by the treating doctor, anaesthetist, radiologist, blood supplier and paramedics.

The member’s estate faced unpaid bills of R36 488 for charges that exceeded the scheme rates. Fortunately, the treating doctor put a message on his bill to the effect that it related to a PMB and should be covered in full.

The widow queried all the unpaid bills, and the scheme then settled them in full, because they related to emergency treatment.

The administrator claimed the procedure codes and diagnostic (or ICD10) codes were incomplete, resulting in the claims not being identified as PMBs and paid as such.

6. The standard treatment that is not suitable

Many members lose out on their scheme’s paying for their treatment of a PMB because the standard treatment is not suitable and their doctors recommend alternatives.

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. Treatment provided in state healthcare facilities is regarded as the absolute minimum.

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.

A member of a large open scheme had to take her case to the Council for Medical Schemes when, after the standard treatment failed, the scheme refused a R10 000-a-month biologic recommended by her doctor for rheumatoid arthritis.

The scheme argued that the biologic was not cost-effective, but it did not recommend an alternative and neither did her doctor, leaving the member in constant pain. Days before the appeal was finally to be heard, the scheme agreed to pay the cost of the biologic.

In cases where treatment is expensive and the consequences of not following the treatment are dire, a doctor may help a member to claim by motivating for alternative treatment.

7. Establishing what is and isn’t covered by the PMBs

The minimum treatment standards for each PMB condition in the regulations under the Medical Schemes Act are often vague, referring only to “medical management” or “surgical management” of the condition.

As schemes are obliged to provide a standard of care for a PMB condition that is at least equal to that provided in state healthcare facilities, they often reject treatment for a PMB condition, saying it is not common practice for public health facilities to provide such treatment. Members can find it difficult to prove otherwise, as cases that have come before the Council for Medical Schemes and its Appeal Committee show. In 2010, two members of a large open scheme won their cases after the scheme refused to pay for reconstructive surgery following their mastectomies. The Appeal Committee found that reconstructive surgery was the prevailing practice in state hospitals.

8. The PMB that is paid only after reams of paperwork

Many members give up the battle to have a claim paid as a PMB when they are confronted with multiple forms that schemes insist must be completed before the claim will be paid, or when forms for chronic conditions have to be resubmitted annually. It can be difficult to get these forms completed by busy practitioners, and some practitioners charge for the time it takes them to complete the forms.


Dr Johan Pretorius, the chief executive officer of Universal Healthcare, a healthcare management company, provides a typical example of how difficulties in the diagnosis of an illness can mask a prescribed minimum benefit (PMB). This can result in a medical scheme member being out of pocket, because he or she has to fund medication and treatment until a PMB is confirmed.

Mrs X had acute abdominal pain, which persisted over several days. The pain was worse after meals, and she was constantly nauseous.

A visit to her general practitioner (GP) resulted in a diagnosis of irritable bowel syndrome (spastic colon), and Mrs X was given pain medication to alleviate the worst of her symptoms.

The medication made little difference, and that night Mrs X was taken to the emergency unit at her local hospital. Tests were performed, but these proved inconclusive, so she was put on a drip in the emergency unit. Later, Mrs X was sent home with stronger pain medication and anti-inflammatories. At this stage, her condition was not a PMB, and she was therefore required to pay for the tests, as well as the treatment received at the emergency facility, from her medical savings account.

Back at home, very little changed. The pain was now so severe that an emergency appointment was made with a gastroenterologist, who examined Mrs X, conducted additional tests and diagnosed her as having gallstones, resulting in inflammation of the gallbladder (acute cholecystitis). Mrs X was admitted to hospital immediately, because if left untreated, acute cholecystitis can progress to gangrene or perforation of the gallbladder.

Gallstones and acute cholecystitis constitute one of the 270 conditions that, in terms of the PMB regulations, must be covered, along with all emergency conditions, which Mrs X’s case had clearly become.

While the earlier, mistaken diagnosis of irritable bowel syndrome was not a PMB, once the correct diagnosis had been made, it was clear that the medical condition was a PMB.

Only an astute and well-informed healthcare consumer who knows her way around the PMB conditions would be able to make the necessary representations to her medical scheme.

Pretorius says Mrs X would have to go back to her GP and the hospital and ask for their help in coding her claims so that they reflected the correct diagnosis. In this way, she will be able to motivate that her medical scheme settles her claims in full for the treatment received.

* This case study was first published in the April 2014 edition of CMS News.

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