No one cares about your health more than you do. To become a truly effective patient, you've got to be deeply invested in promoting your own health.
Learning as much as possible about your condition is a simple matter of self-preservation. Even under an ideal health care system (which, most assuredly, we don't have,) doctors won't always have the time or the inclination to discuss every important aspect of all your medical conditions. The more you teach yourself about those conditions, the better off you'll be. You'll be better able to interpret what your doctor is saying, and you'll even be able to steer your discussions into the areas that are most pertinent to you. You'll have a better understanding of what your doctor thinks should be accomplished, and a better grasp of what you can do to help accomplish it. Knowledge allows you to become an active participant, rather than a passive one, in managing your health care.
Bringing up your financial concerns to others is difficult — especially if you don’t know what to say, or who to ask. It's not always clear who the best person is to answer your questions, so talking with your doctor is a good start. Try starting the talk by saying: “I am worried about costs related to my treatment. Can we talk about my concerns?”
Your doctor may not have all of the answers to your financial questions but they can guide you to help you get the best possible information. And, people from your medical aid company can help on questions about your specific health care coverage.
Next, use the questions below to help focus the discussion. You don’t need to ask all of these questions – just choose the ones most important to your diagnosis and your financial situation. Select the ones you are most concerned about, and ask those first. If you think the doctor is the best person to answer your questions, let the doctor’s practice know ahead of time that you have some questions that you’d like to ask the doctor during your appointment, so enough time can be scheduled.
Who handles concerns and questions about medical aids in the practice?
Will this person be able to help me work with my medical aid company?
Will this person help me figure out my medical bills and the codes on the bills to make sure they are correct?
If a claim is denied, who can help me file an appeal?
Is there a limit to how much my medical aid will cover for my treatment? If so, are my medical bills likely to reach that amount?
Does the doctor have a practice billing policy in place?
Do they offer any payment plans?
How much is my co-pay for each visit?
When is this payment due?
Will I be billed separately for laboratory tests, such as blood tests? Are they covered under my medical aid option?
Who can help me estimate the total cost of the recommended treatment plan?
If I cannot afford this treatment plan, can we consider other treatment options that don’t cost as much?
Does my medical aid need to approve all of the treatment before I begin the treatment?
Is the treatment facility you are recommending in my health plan’s network?
If I need to be admitted into the hospital, what is covered under my medical aid plan?
If I receive treatment as an outpatient, what is covered under my medical aid plan?
The Prescribed Minimum Benefits (PMB) legislation was introduced to ensure that patients receive a minimum of care for a defined group of conditions or injuries, despite the registered benefits of their medical scheme plan option. The legislation forms part of the Medical Schemes Act No 131 of 1998 (amendments to regulations 7 & 8 were published in the Council for Medical Schemes Circular 9 of 2003). [view legislation]
With increasing healthcare costs & new technology, as well as varying benefit designs on medical scheme plan options, patients find themselves in the situation, much earlier in the year than before, where they have run out of insured benefits. It is imperative that patients ensure that they receive their cover as per the PMB legislation from the beginning of the year – and not wait until their benefits or saving accounts are depleted.
What conditions and illnesses are covered?
The following has to be covered in full by the schemes
This includes more than 5,500 ICD-10 diagnoses codes. An ICD-10 code is the diagnoses of a patient’s condition in a code format.
An emergency medical condition means the sudden and, at the time, unexpected onset of a health condition that requires immediate medical treatment and/or an operation. If the treatment is not immediately available, the emergency could result in weakened bodily functions, serious and lasting damage to organs, limbs or other body parts, or even death.
The list of 270 medical and surgical conditions (also referred to as the Diagnosis Treatment Pairs (DTP’s) [view list of 270 conditions only] includes all major conditions, cancers and injuries of the heart, brain, lungs, bones and other vital organs. For these conditions, it is important to ascertain which diagnostic codes are included and exactly what treatment and care is included. [view list of all diagnoses codes and legislated care]
The 25 most chronic conditions listed on the Chronic Diseases List (CDL conditions) are included in the 270 PMB conditions. They are however specified in more detail in the form of legislated treatment steps.
What has to be paid?
All costs related to the:
The scheme must cover the costs incurred during the process of making the diagnosis of a PMB condition. This includes, but is not limited to, consultations, blood tests, ECG’s, X-Rays, Scans and even diagnostic procedures (like gastroscopies and colonoscopies).
The treatment is well-defined for the 25 chronic diseases, including comprehensive care like the diabetic patient’s annual follow-up at the ophthalmologist and the regular blood tests for the patient with renal failure.
For the other PMB’s it is important to read the legislation carefully, in order to establish what is covered for your specific condition Treatment can be very specific (i.e. chemotherapy or 21 days in hospital) or comprehensive (i.e. medical, surgical). Where surgery is included, even the costs for the prosthesis & other products must be covered in full (provided that it falls within the level of care which would have been provided in the academic state hospitals)
Medical treatment includes prescription drugs & medication. Included also is healthcare services like cost of rehabilitation (physiotherapy for the spinal injury patient & speech therapy for a stroke patient).
The care costs for your condition includes all the additional products required to manage your PMB condition (like plaster cast, insulin syringes, colostomy bags, wound dressings and bandages).
Schemes Rights and Responsibilities
Schemes are allowed to put the following measures or processes in place to manage costs:
Treatment Protocols & Benchmark treatment
Formularies (list of specific medicines)
Pre-authorization or Registration processes
Appoint designated service providers (DSP’s) to render services for the PMB conditions to the patients on a specific plan option. A scheme can thus appoint (and insist) that a member goes to a specific group of GP’s, specialists, hospitals, pharmacies, etc (even those in the State sector)
Impose a waiting period or exclusion if you have recently joined the scheme.
Schemes have to cover, at minimum, the standard of care provided in the State sector, including investigations, prosthesis & medication.
If a patient adheres to the above, then the scheme has to pay the costs in full.
Certain schemes are excluded from the PMB legislation as most of the bargaining council schemes do not fall under the regulatory framework of the Department of Health. [list of schemes excluded]
The scheme does not always have to pay in full and may impose a co-payment when a patient voluntary* chooses to
visit a non-DSP (e.g. not to go to the scheme’s designated GP) or
use non-formulary medication (e.g. patient does not want to use the scheme’s formulary drug which is maybe a generic drug but opts for a more expensive drug – without trying the generic medication first).
The co-payment can be the difference between the amount charged and the chosen DSP’s fee or a % of the non-DSP’s fee.
However the scheme must pay the costs in full if:
the formulary medication wasn’t effective, or
the patient had no choice but to visit a non-DSP (an involuntary* non-DSP service)
A service is seen as *involuntary when
The scheme hasn’t appointed any DSP
DSP couldn’t render the services without unreasonable delay
Service is not available from the DSP
Immediate care or treatment was required
DSP not available within reasonable proximity (usually this viewed as approximately 20km but is not a strict rule)
Patients' Rights and Responsibilities
Patients cannot expect healthcare professionals to be fully aware of the 300 different medical scheme plans’ appointed DSP, pre-requisite or insured rates.
It therefore remains the patients’ responsibility to familiarize themselves with the PMB-related processes and conditions of their individual schemes.
Patients are therefore advised to
Obtain the correct and clinically appropriate ICD-10 code from their service providers (e.g. doctor and pharmacist)
Enquire with their scheme whether it is a PMB condition; if so, are there any pre-requisites like
First registering the condition as a PMB
Having to go to certain DSP’s (Designated Service Providers)
Using certain medication first (e.g. generic medicines)
Treatment Protocols and Formularies
If it is a PMB, ensure that the above ICD-10 code is supplied on all PMB condition related accounts like the X-Ray from, prescription and blood test forms.
Ensure that the scheme processes and reimburses all PMB-related accounts correctly which means
Not from savings accounts
Where appropriate, ensure that the scheme pays your service provider in full for DSP and Involuntary non-DSP services.
In line with the PMB restrictions on waiting periods and exclusions [view PMB impact on waiting periods]
Schemes tend to demand considerable paper work when
a healthcare provider tends to ask more than the rate at which your plan is insured for or
when the patient request a benefit which is not part of the standard insured plan option. It remains the patient’s responsibility to ensure that the necessary validating paperwork is provided.
Best is to agree with your healthcare service provider on the assistance required from him or her, and at what costs if any.
There are no fixed regulated prices for services rendered by doctors; sometimes a scheme might have contracted with some doctors or specialists at certain rates. It remains the responsibility of the patient to know what rates the scheme is prepared to pay. Cost for these services remain the responsibility of the patient.
In terms of section 6 of the National Health Act of 2003 and section 53 of the Health Professions Act, the treating doctor must inform the patient the fee for which he intends charging for services to be rendered. Obviously within medicine one must allow for acceptable deviances.
Doctors should also inform the patient of the long term benefits of quality care with a co-payment (for expert service or non-formulary medication) vs Short term saving by eluding a co-payment.
And if the Medical Scheme does not comply?
Should you not be successful in solving your PMB-related queries with the Call Centre of your scheme, then address it with the scheme’s principal officer and the scheme’s dispute resolution committee.
If a patient or service provider fail to find an acceptable resolve with the applicable medical scheme, then contact the Department of Health’s regulatory body overseeing medical schemes, the Council for Medical Schemes, on (012 431 0500)
|Case studies and more information|
The following two cases studies illustrate many of the various aspects and issues to be considered with PMB conditions, their treatment and medical scheme actions.
For more information on PMB’s and Frequently Asked Questions, visit the website of the Council for Medical Schemes. [visit CMS website]
An ICD-10 code is the diagnoses of a patient’s condition in a code format. There are more than 45,000 ICD-10 codes and combinations, so please appreciate and understand your healthcare provider’s time to making sure that they give you the correct code when treating you.
ICD-10 stands for International Classification of Diseases and Related Health Problems (10th revision).
It is a coding system developed by the World Health Organization (WHO), which translates the written description of medical and health information into standard codes. For example, H65.9 is for acute otitis media (middle ear infection) or S62.50, which is the code for a closed fracture of a thumb.
According to Regulation 5F of the Medical Schemes Act of 1998, all accounts submitted to your medical aid for the services rendered to you has to contain a diagnosis in the form of an ICD-10 code. Medical Aids can legally decline a payment for a claim if no ICD-10, or an incorrect ICD-10 code has been submitted on your claim.
An ICD-10 code consists of an alphabetical and numerical character. The alphabetical character will always be in the first position, followed by the numerical characters H71. It can consist of three, four, or even five characters – and it has to be specified to a maximum character level where possible. Sometimes it even requires more than one code for one condition.
The ICD-10 codes provide accurate information on the condition you have been diagnosed with and these codes help your medical aid to determine what benefits you are entitled to and how these should be paid. This becomes very important if your condition is a PMB condition, as these can only be identified by the correct ICD-10 codes. If no ICD-10 codes are provided, or if the incorrect ICD-10 codes are given, the PMB-related services could be paid from the wrong benefit such as your medical savings account, or it might not be paid at all if your day-to-day or hospital benefit limits has been exhausted.
It is not a legal requirement for your health provider to provide the ICD-10 code on a prescription, blood test or X-Ray request form.
Even if you pay the doctor upfront, it is essential that your healthcare provider gives you, or submits an account to your medical aid with the correct ICD-10 codes in order to get it paid. In the case of your illness being diagnosed as a PMB, the importance of the correct code is essential if you are in need of having, for example, a second scan and your medical aid will normally only pay for one scan per family per year. If the correct code is given, your medical aid will be obliged to cover and pay for the cost of the second scan as well.
You have the right to inform your healthcare provider that you do not want to have the ICD-10 code disclosed on your account. In such a case, your healthcare provider will then use the code U98.0 (Patient refusing to have clinical information disclosed). By requesting this, your medical aid might not pay the account if certain benefits have been depleted.
Council for Medical Schemes
Telephone number (012) 431 0500 / 0861 123 267 (Shared Call)
Fax General: (012) 430 7644 or
Fax Complaints: (012) 431-0608
E-mail Enquiries: firstname.lastname@example.org
E-mail Complaints: email@example.com
Postal Address Private Bag X34, Hatfield, 0028
Physical Address Hadefields Office Park, Block E, 1267 Pretorius Street, Hatfield, 0028
Rights & Responsibilities of Scheme
Time limits for dealing with a complaint
The final response
Appeal to Council
Appeal to the Appeal Board
Doctors deal with patients who have different medical aid cover and patients who have no medical aid cover. Where a patient has some form of third party cover e.g. private medical aid, injury-on-duty cover, GAP cover, the treatment and the costs thereof can also be determined depending on whether the patient still has some cover left over for the specific treatment, or whether they have completely depleted their benefit cover for the year.
|Does the doctor charge “contracted in” fees?
This is a common question asked by patients. Unfortunately the answer to how a doctor charges is not an easy one as it depends on many factors within the doctor’s practice. In the private medical aid market there are over 105 different medical aids with more than 300 different medical plan options. All these medical aids and these plan options have various ways in which they will cover and reimburse a medical doctor for the healthcare services rendered. For example;
Because of all these variations in medical benefit cover and the different reimbursement rates applied by the different medical aids, patients should not always expect the doctor or practice staff to have all the information available on the different reimbursement rates and healthcare covered by the patient’s medical aid plan.
Even if your medical aid does cover a certain operation or procedure, the medical aid might decide not to cover all the codes charged for by the treating doctor. They might also impose co-payments on the patient like 20%, or an upfront payment of R5, 000.00 for in-hospital treatment. This depends on the medical aid plan rules the patient belongs too.
It is very important that the patient should enquire and discuss the healthcare treatment plan and the costs associated to the treatment with their doctor. This should be done and agreed upon before any treatment is given or undertaken. A patient is entitled to ask for a formal written quote from the treating doctor which includes the expected treatment envisaged and the cost of the treatment.
It is important for patients to understand than a pre-authorization number given by the medical aid for a procedure is not always a guarantee that they will necessarily pay all the costs incurred when undergoing a procedure or when consulting a medical specialist doctor.
Should your medical aid request that your doctor completes certain registration forms or has to provide a motivation letter to your medical aid, the doctor can charge for the additional paper work submitted.
What should patients do?
For patients with medical aid cover, the onus still remains on the patient to know what is covered on their plan and how much their medical aid will pay and if there are any pre-requisites or conditions that they may have to adhere to before seeking treatment.
Even if the doctor decides to send the account to the patient’s medical aid for payment, it still remains the responsibility of the patient to ensure that the account of the doctor is covered and paid for. In the event of the patients medical aid not paying the doctor directly, or only paying in part for the treatment given, or paying the patient directly and not the doctor, the patient is at all times fully liable for the full costs incurred and the doctor is legally entitled to charge interest and any other costs incurred in the recovery process in the event of an account not being settled in full by the patient.
Over and above the mentioned issues concerning costs and fees, patients do have further rights concerning their diagnosis, management and the treatment options available. One of these is the right to a second opinion if need be.
If a patient’s medical aid cannot clarify at which rates they are insured at, patients can submit complaints to the Council for Medical Schemes. firstname.lastname@example.org; Tel 012 431 0500
If patients are uncertain of their rights and those of the doctor, or should they have any further questions, they should not hesitate to ask the practice staff or their doctor.
Take some time to go to the tabs on this page and to familiarize yourself on what fees your doctor is allowed to charge for, your rights as a patient in our healthcare market place and the mandatory treatment cover you have under the PMB legislation.