• 30 Mar 2015

    SpesNews Volume 115

    REGULATION 8 AGAIN (PMBs at cost)

    According to a 6 March Times article, the South African Municipal Workers' Union Medical Aid (SAMWUMED) and Genesis Medical Scheme have taken Minister of Health, Aaron Motsoaledi, to court to have the regulation requiring cover of prescribed minimum benefits, struck down. The regulation in particular that is causing the court action states that a medical scheme should reimburse a service provider at cost regardless of the benefits a patient has available and regardless of cost.

    The principal officer of the SAMWUMED, Neil Nair, however states that the article did not convey the intention of the scheme accurately and that SAMWUMED has withdrawn from the high court application to rather have the matter addressed via a Task Team (established by the Department of Health) that has been instructed to find a resolution to the much debated regulation 8 of the Act. Nair is of opinion that this course of action would lead to a more expeditious resolution to the problems brought about by the current interpretation of Regulation 8. SAMWUMED is a participant in the Task Team.

    Dr Anban Pillay, the current deputy director-general of health, indicated that the aim is to find a solution that will be fair to patients, providers and funders.

    In terms of the ethical rules and guidelines issued by the HPCSA, a service provider may not differentiate between what they would charge for a PMB vs a non-PMB condition. This is viewed as exploitation of the PMB legislation. Furthermore, should a service provider charge more than the HPCSA guideline tariff, agreement to the tariff being charged as well as written consent from the patient are requirements prior to the delivery of services. Some schemes are assessing and constantly evaluate the billing policies of the practices. The Medical Schemes Act further allows for a scheme to implement risk-management managed care interventions such as formularies, protocols and the establishment of a designated service provider network.

    It would certainly seem that a fair amount of cost containment options are already available to schemes to manage the risk that stems for the current interpretation of regulation 8. The question that deserves an answer most would probably be “Why are some medical schemes not implementing these cost containment measures in full rather than opt to amend the Act or target the tariffs practices are charging?” All factors considered, the current ratio of patient to specialist probably would indicated an acute shortage of specialists on a national level.

    The article further quotes Christoff Raath, joint CEO of Insight Actuaries, as saying that some specialists charge significantly more for PMB procedures than for illnesses not covered by the minimum benefits. Raath said that it was not illegal for doctors to charge what they wished. One interpretation is that the law as it currently applies does not incentivize the practitioner to enter into price negotiation. This is extremely interesting as some Designated Service Providers networks, despite the current state of affairs, already incorporates the majority of the South African medical specialists.

    SpesNet would like to caution practitioners making use of 3rd party vendors for the drafting and/or submission of clinical motivations – in particular PMB motivations. Clinical reports should ideally solely remain the domain of the treating clinician both from ethical and clinical perspective. More information on this subject will be communicated as it develops.

     

    FEDHEALTH AND GEMS COORDINATION OF CARE

    Both GEMS and FedHealth Medical schemes implemented a General Practitioner (GP) or Family Practitioner (FP) referral system for patients requiring the services of a specialist. This is in an effort to coordinate care delivered to the patient and would require the patients to obtain a referral number from their respective GPs (for Fedhealth) or FPs (for patients on the GEMS Beryl and Sapphire options) PRIOR to making a specialist appointment. The Fedhealth referral system has been implemented on 1 March 2015 and that of GEMS will kick off on 1 April 2015. The schemes can be contacted at the following for further information:

    GEMS (0860004367 or email: enquiries@gems.gov.za)

    Fedhealth (0861 112 666 or email: specialist@medscheme.co.za)

    Please be reminded that Bonitas medical scheme also currently operates on a GP referral base for their Standard and Primary options.

    GEMS CODE 0008/0009 AND 0011

    Following the previous communication in SpesNews version 114 regarding the problems currently experienced by GEMS in the code processing department, SpesNet has been informed that the following codes also appear to be problematic for the scheme to manage:

    Code 0009 / 0008 and 0011.

    Please be advised that rejections on these codes are expected and that practices should please query these claims on a monthly basis to ensure the claims does not become stale.

    ANNUAL REGISTRATIONS:

    Please note the following 2015 registration information

    HPCSA Registration

    Due by

    Amount

    Specialist

    1 April

    R1 424

    General Practitioner

    1 April

    R1 397

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