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A recent case has again raised the question of whether medical schemes are adhering to regulations on prescribed minimum benefits (PMBs), which schemes are required to provide from your risk benefit (not medical savings account) for certain life-threatening conditions.
When Victor Tredinnick, 25, was diagnosed with thoracic outlet syndrome (TOS), a PMB condition, three years ago, Discovery Health Medical Scheme (Discovery), did not pay the doctors he consulted in full. However, after Personal Finance intervened, Discovery did a U-turn and paid in the difference.
Bevan Collins, managing partner of Harnacks Brokers in Cape Town, confirmed the Council for Medical Schemes (CMS) ruling that if there is no network doctor (DSP) in the area, then a scheme must pay the full rate.
“A medical scheme cannot refuse to treat a condition if it is a PMB. It is the treating doctor’s role to provide the correct ICD10 diagnosis code (see ‘What is an ICD10 code?’) to the patient and the medical scheme.
“Once this has been provided it becomes the medical scheme’s obligation to recognise and confirm the condition to be a PMB. The scheme will then register the patient on the correct chronic disease programme,” Collins said.
“Once the patient has been registered, then a treatment-care protocol must be put in place, usually linking the patient to the scheme’s network of doctors. If the doctor network is used then all costs will be funded, even if the patient is on a low-cost hospital option. Problems can and do arise if the patient chooses to use non-network doctors.
If there is no network doctor, then the PMB rules allow for the patient to be treated by non-network doctors,” Collins said.
According to Vicki Veale-Gilbert, Tredinnick’s mother, Discovery’s
call centre agents referred her to general surgeons, not vascular specialists. One practitioner specialised in haemorrhoids.
Eventually, an agent referred Veale-Gilbert to a vascular specialist, Dr A, who, during a two-hour consultation, explained what they were up against. She filled out PMB forms and recommended a physiotherapist, but Discovery refused to approve this, Veale-Gilbert says.
“We received an email that Dr A was not a DSP. Discovery took months to pay her,” Veale-Gilbert said. “And they refused to pay in full the other doctors we consulted, even though the CMS rules say they must pay if there is no DSP in the area.”
Tredinnick works in the film industry and is on Discovery’s Smart Classic plan, said Veale-Gilbert. “Victor started complaining of a sore left shoulder and arm more than two years ago after he’d had a fall while playing tennis. Victor’s GP prescribed anti-inflammatory medication.
“On his way home to Cape Town from a shoot, he said he couldn’t drive any more as his arm and shoulder were too sore. He arrived home and his left arm was turning blue and was twice the size of his right one and, as he suffers from asthma, he found it hard to breathe.
“I rushed him to Constantiaberg Emergency, which admitted him and did tests. Victor was put on drips to prevent clotting and when he said he was able to inject himself, he was discharged and given a script for Clexanne injections, which cost R7770 a week.
“Discovery refused to pay for the injections, but when I appealed to the CMS they reimbursed some of the money,” Veale-Gilbert said.
Tredinnick subsequently had major surgery, which included removing a rib. The clot dissolved but it left his sub-clavian vein diseased and scarred. There were complications during the operation: his lungs started to collapse, he developed an infection and was discharged with a large haematoma in his chest cavity.
“Victor was readmitted to Kingsbury under the care of another specialist. Until then no-one had explained the severity of TOS to us,” Veale-Gilbert said.
“We have agreed to pay (Dr A) in
full as an ‘operational loss’ to
correct an error caused by ourselves where a member has experienced a negative financial impact as a result,” Discovery said.
Later, Discovery sent Personal Finance a document it emailed to Veale-Gilbert in August explaining the basket of PMB benefits. It authorised treatment for TOS; agreed to pay for Clexanne as well as an alternative, Discovery told Veale-Gilbert.
However, it would pay the other specialists Veale-Gilbert consulted only up to 80% of the scheme rate, as they were not DSPs. Veale-Gilbert was still unhappy, so Personal Finance went back to Discovery, which reversed its original decision and agreed to pay 100% of its rate to the doctors Tredinnick consulted.
Felicity Hudson, spokesperson for Discovery, said: “As there is no DSP in the member’s area, we will pay 100% of the medical aid rate to the doctors Tredinnick consulted. There is a specialist vascular surgeon, who is a contracted DSP, for in and out-of-hospital treatment, and Discovery will fund the costs of this doctor in full, and Tredinnick is welcome to contact him, to confirm treatment for their registered chronic condition.
“Currently, the request for physiotherapy has been declined funding from PMB, as the requested conditions do not form part of the defined list of conditions. These requests are reviewed based on the clinical information supplied by the treating providers. We will review any further applications for physiotherapy based on the codes provided and whether or not these form part of the PMB diagnosis,” Hudson said.
“Discovery Health Medical Scheme endeavours to provide rich funding and maximum use of benefits to members in need,” says Dr Ryan Noach, the chief executive of Discovery Health.
“In order to ensure maximum funding of health professional accounts, Discovery has successfully contracted with almost 90% of doctors across South Africa through payment arrangements. These payment arrangements, which are specific to particular Discovery plan types, allow Discovery members to carefully select doctors where they have full cover choices,” says Noach.
“Doctors with full cover benefits also form an important network of designated service providers (DSPs), as defined by the Medical Schemes Act, for the purposes of full prescribed minimum benefit (PMB) cover.
“In the experience of this member, unfortunately our call centre incorrectly advised the member about DSP networks on a call during January 2019.
“As a result, the scheme will cover all costs relating to the period of co-payment exposure emerging from this incorrect call centre advice. This was human error by a call centre consultant, who has been carefully re-educated to ensure no recurrence of such error.
“Prior to this error, and subsequent to the error being recognised, all claims have been funded correctly, compliant with scheme rules and the provisions of the Act in relation to the member’s PMB condition,” says Noach.
“We regret this human error and apologise for the inconvenience. We are thankful that we could correct the claims that resulted from this erroneous advice,” he says.
The ICD10 code, or International Classification of Diseases and Related Health Problems (10th revision), was developed by the World Health Organisation and converts medical and health information into standard codes. These treatment codes must be determined by your doctor and should appear on your bill. Certain ICD10 codes are for prescribed minimum benefit (PMB) conditions. The list of PMB conditions and their codes are available on the CMS website. Visit www.medicalschemes.com/medical_schemes_pmb/