Practice code numbers not always needed

01 October 2013 Andre Jacobs, Gusto Health

While South Africa gears itself up for the implementation of the National Health Insurance programme, it is evident that the South African medical industry needs to be regulated to iron out a number of legal issues which are starting to surface in the industry, says Andre Jacobs, CFP®, CEO of Gusto Health.

The appeal committee, which was established in terms of the Medical Schemes Act, recently ruled on 29 July 2013 that claims submitted by a doctor who lawfully rendered a health service and there are no allegations of fraud or any wrongdoing must be paid by medical schemes in terms of their rules.
The appeal was brought by the Government Employees Medical Scheme (GEMS) against a decision made by the Registrar of Medical Schemes. The decision stated that GEMS must settle the claim according to their rules despite the fact that the doctor did not provide a Practice Code Number (PCN).

Dr Burman conducts a lawful cash based practice, but has chosen not to register with the Board of Healthcare Funders (BHF) and to obtain a PCN. There are also no allegations of fraud or other wrongdoing on the part of Dr Burman.

Landmark ruling

This is a landmark appeal case in the sense that the absence of a PCN will no longer disqualify beneficiaries of medical schemes to get the claims paid. This case is important to doctors, beneficiaries, members of dispute committees and brokers that advise clients about their rights and obligations as medical scheme members.
This does not mean that PCN’s will never be a requirement. This appeal case focused specifically on Section 59 of the Medical Schemes Act and Regulation (specifically regulation 5e) of the regulations promulgated in terms of the Medical Schemes Act.

In deciding the appeal, the appeal committee also considered a judgment handed down by the Supreme Court of Appeal (SCA) in KwaZulu-Natal: Joint Municipal Pension Fund v Endumeni Municipality [2012] 2 All SA 262 (SCA). In this judgment the SCA said the following: "The inevitable point of departure is the language of the provision itself, read in context and having regard to the purpose of the provision and the background to the preparation and production of the document."

Regulation 5(e) states that the accounts by suppliers of services mentioned in section 59(1) of the Medical Schemes Act must contain the practice code number, group practice number and individual provider registration number issued by the registering authorities for providers, if applicable, of the supplier of service. The words if applicable require some flexibility in requiring that a PCN be reflected in an account.
No limitations

Regulation 5(e) does not limit the instances in which it may not be applicable to require a PCN to be reflected in an account. In this case, the doctor runs a cash practice and did not obtain a PCN from BHF. However, in cases where a doctor is has obtained a PCN from BHF, the accounts must still contain the PCN as required by regulation 5(e) of the regulations promulgated in terms of the Medical Schemes Act.

Medical schemes are becoming more technical, and it would serve members of medical schemes well to appoint an accredited and competent broker who is a member of a professional body with a disciplinary code and a code of conduct to advise them on their rights and obligations.

It is clear from the latest annual report published by the Registrar of Medical Schemes that more members made use of a broker in 2012 than in any other year. Competent brokers add huge value to members of medical schemes as well as to the Health System in South Africa.
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