When Moneyweb reader Angela Drescher contacted us almost a month ago, we decided to test her allegation that information about prescribed minimum benefits (PMBs) is largely inaccessible to members of local medical schemes, which results in them being denied benefits they are entitled to by law.
PMBs are conditions that medical schemes have to cover by law to a prescribed minimum standard. They consist of three parts: a list of chronic conditions, medical emergencies and a further list of 270 conditions.
Drescher says: “My experience is that many medical practitioners and medical aid schemes do not disclose PMB conditions or their Diagnostic & Treatment Pairs (DTPs).” According to the Council for Medical Schemes (CMS): “a DTP links a specific diagnosis to a treatment and therefore broadly indicates how each of the approximately 270 PMB conditions should be treated.”
Point of departure: The list
Moneyweb’s point of departure was that for members to ensure they get the benefits they are lawfully entitled to, they have to know what these benefits are. Getting the list of conditions covered would therefore be the starting point.
A quick Google search showed that information about the 26 chronic conditions is widely available, including on the websites and brochures of medical schemes. The list of 270 conditions, however, proved very difficult to find.
Both the Department of Health and the South African Medical Association referred Moneyweb to the CMS. The list was not available on the CMS website. Following our media inquiry for the list, CMS spokesperson Dr Elsabè Conradie sent us the list of 26 chronic conditions and some examples of the other conditions covered, but not the full list of 270 conditions. It was only after we insisted, that she consulted the CMS clinical division and forwarded the full list with PMB codes and treatments covered.
The list includes conditions like major affective disorder (which includes major depression), acute otitis media (inflammation of the middle ear) and pregnancy.
‘We don’t have the list’ – BestMed
Moneyweb then asked five medical scheme members to request the list of 270 conditions, their diagnostic codes required by the medical schemes for payment, and the treatment covered, from their schemes.
Not one of these members was given the list following their initial requests.
BestMed responded: “With reference to below, I hereby would like to inform you that BestMed does not have a list of PMB conditions with the ICD10-codes as each condition diagnosed has a number of codes that describe the condition.”
We challenged this and BestMed responded: “The PMB ICD10-codes are encrypted into our data base of clinical services but there is no ‘report’ that can be printed out or e-mailed to an external person. There are more than 270 identified PMB conditions – each with anything from 1 – 10 sub-divisions and such a report is just too large to be provided to external parties and furthermore it is not part of a medical scheme’s daily operations to provide such reports.”
BestMed did refer us to the CMS website, where it was not available at that stage.
Meant for internal use only – Momentum
Momentum Health initially responded: “Please be advised that the format in which the scheme has the below list available is meant for internal use only, and we are unable to send that externally. The information is integrated into our processing system.
However, the requested information should be available on the internet.”
It did however send the list after the member challenged the initial response.
Supplying other information – Discovery, GEMS
Discovery Health, which was approached by two members, immediately sent its members two brochures, the one focusing on the chronic diseases and the other dealing with PMBs in general, including the 270 conditions. It gives some examples of what is being covered and refers the reader to the CMS website for more information. It did not supply the list as such.
GEMS also failed to supply the list, but gave background information about PMBs, including the 270 conditions. It referred the member to the CMS website for the list.
Moneyweb discussed the responses with the regulator, who was very critical about especially BestMed’s and Momentum’s responses. CMS general manager for legal services Craig Burton-Durham actually said a reasonable inference can be drawn from their responses that these two schemes are trying to deny members benefits they are entitled to.
Burton-Durham requested Moneyweb to forward these responses to the CMS for it to address the failure of the two schemes.
The CMS also recognised the need to publish the list of 270 conditions and added a link to the full list, with relevant codes and levels of treatment covered, on its website.
He said schemes have a legal obligation to inform members pro-actively of the benefits they are entitled to if the member, for example, submits a claim for a conditions that may qualify as a PMB, without realising that it does.
‘Trying to stir’
Moneyweb then sent a media inquiry to each of the four schemes, indicating the position of the CMS and giving them a right of reply.
BestMed general manager of managed healthcare Riaan du Plessis called Moneyweb, accusing the writer of “trying to stir” and being unfair. He then said our member inquiry was dealt with by a junior staff member who did not handle it correctly and has been reprimanded. He had the list forwarded to us within minutes after ending the call, saying in the email: “The response provided to you on 11/08/2015 was technically incorrect as the PMB list and relevant coding is published by the Council for Medical Schemes (CMS) and is public info.”
Momentum sent the following response: “I sincerely regret the service interaction that Hanna (the member) had with our call centre. Even though the list of Prescribed Minimum Benefit conditions are readily available in the public domain, it represents no excuse for us not providing this information when specifically requested to.” It also said the service failure was addressed to prevent it being repeated.
Discovery Health sent a lengthy response (read its response here), saying: “Whilst we do not specifically respond with a list of all 270 PMB diagnoses, we provide clear direction to members about where they can access this information, which is in the public domain. We absolutely have no reason whatsoever to withhold this list from members, though in the past we have not found it helpful to email out a long list of clinical diagnoses.” Discovery further says the list of relevant PMB ICD-10 codes contains 7 500 separate codes and the scheme works with healthcare professionals to ensure the use of the right codes.
GEMS agreed with Moneyweb that the list should be on their website, thanked Moneyweb for pointing out the oversight (read its response here) and published it at this link: http://www.gems.gov.za/default.aspx?3VOLM3SLyFodCw/bCM2OPY2YlfvhqW38
The CMS in its annual report indicated that the average cost for PMBs in 2014 was R567 per beneficiary per month, representing 52.5% of all risk benefits paid out by medical schemes in that year. It did however admit to Moneyweb that it does not have data about the extent to which these benefits are being denied.
The CMS pointed out that the PMB system is very complex and cover is only at a minimum level. For example, for major depression, cover includes three weeks hospitalisation or 15 sessions of psychotherapy per annum, but not medication.
Members have to adhere to reasonable administrative requirements by medical schemes to access cover, for example registration of these conditions, and have to use designated service providers if the option they are on requires it.
If the designated service provider is however not available, they may use another and the scheme has to cover it in full. The CMS points out that the member may be required to prove that the designated service provider was not available.
If a scheme rejects a PMB claim, it has to give reasons, the CMS says.
According to the CMS, schemes that failed to pay for PMB claims submitted to them to the extent that they should have, can be held liable for the cost three years retrospectively.
Unfortunately, the CMS said, schemes often “only cover it when you moan”.
Tips navigating PMBs
Drescher, who fought for months to get the PMB cover they were entitled to for family members and now assists other people with the same issues, gives the following tips:
- Discuss with your doctor whether your condition is a PMB and check the list for the detail of what exactly is covered.
- Get the form from the medical scheme to register your PMB conditions, have the doctor fill it out and submit it to the scheme. This has to be done separately for hospital treatment and managing the same condition thereafter.
- In consultation with your doctor, get the right IDC 10-codes and ensure it is included on all invoices, prescriptions and pathology reports. Pathology reports may have to be resubmitted once the diagnosis is made.
- Check that the scheme covers the treatment from the risk pool, not your savings account. If not, take it up with them.
- If you are not satisfied with their decision, appeal and if you are still not satisfied, contact the CMS.
- If you are still not satisfied, raise the issue in public via social media or websites like hellopeter.com.