Scheme to challenge 'ambiguous' PMB legislation that protects excessive billing
Samwumed, a restricted, worker-based national medical scheme for municipal staff, is set to challenge a judgement by the Council for Medical Schemes (CMS) in an attempt to deal with what the scheme describes as "carefully orchestrated profit mongering by certain health service providers".
The appeal is against a CMS judgement in a complaint lodged by an anaesthesiologist who claimed payment for services far in excess of the tariff paid by the scheme. The scheme tariff is premised on the national health reference price list, adjusted for inflation in 2007.
Said Neil Nair, fund officer at Samwumed: "The ruling by the Registrar, if not properly challenged, will allow some providers to continue taking advantage of the system to enrich themselves at the expense of medical schemes and their members. While the cartel-like activities of some specialist groups is a cause for grave concern, the CMS ruling seems to vindicate their questionable tactics."
Prescribed Minimum Benefits (PMB) legislation prescribes that medical schemes pay costs on an unlimited basis for any PMB condition. This was intended to protect members from out-of-pocket payments and a reliance on the state when benefits were depleted.
"Ironically, what legislation fails to indicate is what the quantum of this tariff should be, creating a wonderful money-spinning opportunity for some healthcare providers. Some specialists, under the protection of this ambiguous legislation, are billing schemes in excess of 300% of acceptable tariff," said Nair.
He said the Council's judgement was surprising given that the Registrar of Medical Schemes, Patrick Masobe, had noted in a circular last year that schemes were facing high charges for PMBs, and that provision for full payment of PMBs was about guaranteeing access to healthcare, and not about providing a 'blank cheque' to providers.
Despite this, said Nair, Samwumed has been slapped with a far-reaching judgement compelling the scheme to pay the specialist's bill, despite "the obvious moral bankruptcy of its submission".
He noted that the challenge against the practice of excessive billing is not being championed from the quarters one would expect. By not challenging the Competition Commission ruling against aid tariff setting, the Board of Healthcare Funders (BHF) had rendered their commitment to equitable healthcare redundant and their strategy questionable.