Misinformation around PMBs sees rise in CMS complaints
21 November 2013 | Healthcare | Medical Schemes | Dr Jacques Snyman, Agility
Misinformation provided to consumers with regards to what exactly is covered under the payment of Prescribed Minimum Benefits (PMBs) has resulted in a number of complaints to the Council for Medical Schemes (CMS) over the past year.
This is according to Dr Jacques Snyman, MD: Integrated Risk Solutions of Agility Global Health Solutions (Agility), who notes that many consumers mistakenly believe that medical schemes are required to cover all PMBs in full, regardless of the specifics of the condition, or the cost.
"The fact is that not all conditions related to a PMB are covered. For example, a hernia is included on the PMB list but is only funded under specific circumstances such as when the condition is complicated. In these cases, clinical proof such as x-rays, blood tests and scans must be submitted before a medical scheme will cover them and an ICD 10 Code (a unique code per condition) may not be used as the sole verification of the diagnosis according to CMS regulations.”
Snyman notes that PMBs refer to a list of 271 conditions and 25 chronic conditions that all medical schemes are required to fund as a basic benefit to all members. However, the authorisation of treatment for the condition and the level of care at which cover is provided is determined by the medical tests and other clinical verification received by the medical scheme, as well as the parameters and definition of the PMB condition as set out by the CMS.
This process is aimed at protecting the member, as well as the medical scheme, from unscrupulous code shifting/farming that could lead to unnecessary treatment or surgery, Snyman adds.
"Medical schemes are also not required to cover PMBs – or pay in full for the condition – under certain circumstances. If a member is in a waiting period for a pre-existing condition related to the PMB and there is no PMB cover during this time, the scheme may not pay out. Similarly, if the level of care proposed is not deemed appropriate, cover may only be provided for the appropriate level of care e.g. you will not be covered for hospitalisation if you can be treated effectively as an out-patient.”
Snyman lists the following examples of where a PMB condition may not be covered in full:
• If it is not an emergency. An emergency is defined by the CMS as lifesaving treatment that needs to take place immediately to save life or limb.
• If you go to a non-Designated Service Provider (DSP) when one of your scheme’s DSPs is reasonably available. This does not apply to involuntary admissions where you are unable to choose the provider due to incapacitation or if treatment is not available at your scheme’s DSPs. It is important to note that some treatment for PMBs is only provided at a scheme DSP in terms of your option benefits and you should thus confirm this information prior to joining.
• The level of care you receive is inappropriate for the condition e.g. ICU when you could be treated in a general ward.
Snyman encourages consumers to speak to their healthcare consultant to determine whether their medical scheme cover provides the appropriate level of care that they and their family require at every life stage and not leave every eventuality to the accessibility of PMBs.
"It is in the medical scheme member’s interests to question their medical practitioner in depth with regards to their medical conditions and determine the best, most cost-effective method of treatment. This will ensure that there are no additional costs that they must pay for as well as helping to limit medical scheme contribution increases, which will ultimately safeguard the sustainability and affordability of private healthcare in South Africa,” Snyman concludes.
