Medical schemes unite in fight against unfair pricing

Strong support for challenge against 'ambiguous' legislation that lets doctors bleed schemes
 
The medical aid industry has come out in strong support of Samwumed in its appeal against a ruling that allows specialist doctors to claim excessive payment under ambiguous legislation stipulating the minimum set of conditions for which all medical schemes must provide benefits.
 
Said Samumed fund officer Neil Nair: "The combined membership of schemes that have demonstrated their support represents more than half of the entire industry. This is the first time the industry has rallied together outside of the Board of Healthcare Funders (BHF) in pursuit of a mutual challenge."
 
Samwumed, a restricted, worker-based scheme in local government, is to challenge a judgement by the Council for Medical Schemes (CMS) in an attempt to deal with what it believes amounts to "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.
 
"We have concluded," said Nair, "that the CMR ruling that we are liable to compensate at full cost is contrary to the spirit and intention of the legislation which is to provide a framework for equitable member access to care.
 
"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," said Nair.
 
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.