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Antoinette Slabbert

Antoinette Slabbert

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  I am a member of Bestmed and gave birth last year via C Section (had pre-eclampsia). I was left with a R3500 - odd Anesthesia bill that Bestmed did not cover. I called the doctors to make an arrangeme...  

The list medical schemes won’t give their members

A look at the 270 conditions schemes have to cover by law.

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.

Legal obligation

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.

See the list of 270 conditions here.

‘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

PMB utilisation

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:

  1. Discuss with your doctor whether your condition is a PMB and check the list for the detail of what exactly is covered.
  2. 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.
  3. 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.
  4. Check that the scheme covers the treatment from the risk pool, not your savings account. If not, take it up with them.
  5. If you are not satisfied with their decision, appeal and if you are still not satisfied, contact the CMS.
  6. If you are still not satisfied, raise the issue in public via social media or websites like hellopeter.com.



 16 comments

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Congratulations Moneyweb on a very relevant piece of investigative journalism.

I find the difference in the responses from the medical schemes fascinating.
At the one end of the spectrum, one finds the apologies from GEMS and Momentum. Well done – both of you seem to have a good grasp of customer relations and how to fix a shortcoming.
At the other extreme, there is the confrontational approach (and accusation!) from BestMed. Further training definitely required…
From Discovery one gets the “notpology” (which at first glance looks like an apology, but on closer inspection turns out to be mostly self-justification).

I have had a number of run-ins with my medical aid fund, or should I say “my fund’s administrators” about PMB’s and I can only say that they often look for reasons not to pay PMB;s in full and make it difficult for members to get them to do what they should have done without a “fight”.

I know the feeling Snoopy and its because schemes don’t want to pay!
When they do, then that’s when the premium increases start happening more often as they have such high claims and therefore cannot manage their solvency ratios… So as always the consumer pays the prices

As an FA and Medical Scheme Broker i can comment first hand that prior to my joining the industry i had an incident where i was involved in a motor vehicle accident.
I was admitted for a dislocated arm and the treating doctor advised me that he charges above standard rates and i would need to claim from the medical scheme as a PMB.
Once i was out and the bills started to come in i approached the scheme who gave me a run-around for 3 or more months to have doctors etc change codes on their invoices etc to the correct ICD10 codes listed under the relevant PMB’s.

From a medical aid perspective i can confirm that i myself do advise clients of the PMB’s and the scheme provides them with information on the member guide each year, however most people don’t read or understand the complexities of all the paperwork and jargon out there, which is why i feel that having a broker or adviser who deals with medical schemes is imperative!

Unfortunately not much is done from an education point-of-view via schemes, brokers, advisers and even doctors so many people pay for outstanding claims from pocket, when in actual fact it would have been paid for by the scheme directly….

So my advice is get an adviser or broker and have them get involved with your claims and they could possibly save you lots and lots of money going forward!

Very informative articles – so well done Hanna and Moneyweb on this expose. What would be a revelation as a follow up on this article would be what percentage of ones monthly contribution goes into the cost of administering the medical aid fund. Gap insurance seems particularly costly where the company that I was recommended to use by my medical aid company, their admin costs were some 45% of monthly premiums which seems like a rip off of note

One needs only to Google “diagnostic treatment pairs” and the first few hits give the CMS as well as some schemes who have links to the list. While I agree that some schemes try to wriggle out of paying for PMB’s, the list of 270 treatment pairs is freely available and has been for some years. It is certainly not “difficult to find”.

Thank you Antoinette. I am BEYOND delighted with your excellent article, Thank you so very much. You have made all these months I have spent researching PMB’s so worthwhile.
Angela Drescher

Phil99 I don’t think general members of the public would know that “diagnostic treatment pairs” is the phrase to google if you want a list of 270 conditions covered a Prescribed Medical Benefits. Last time I looked, the CMS also only had examples of these on its website, not the whole list. They did publish the list on their website following our interaction, under different heading that is easier to find, though.

Hi Antoinette. True. Having been in the financial services industry (including serving as a trustee on my medical aid), I have (very wrongly) assumed that the phrase would be common knowledge. I forgot the dictum “assume makes an Ass of U and Me (but not U in this case!). Sorry

As the Angela Drescher referred to in the above article, I have researched PMB’s extensively for the past 8 months. While (mostly outdated) copies of the ICD10 Code (not referred to as PMB) list can be found online by people who have access to the internet they would need to have a good understanding of what they are searching for. According to The Council for Medical Schemes , the following are examples of “unfair practices”
1. Complex, legalistic and user-unfriendly information…
2. Focus of information provision primarily to URBAN and ELECTRONICALLY LITERATE BENEFICIARIES.
3. Insufficient information to beneficiaries on how to utilize the benefit system.
4. Non communication of vital information regarding contributions, BENEFITS, rights, pre-authorization requirements, formularies etc.
The ICD10 Code lists online are NOT user friendly e.g. Post Natal Depression PMB 902T ICD10 Code F53.8 reads: “Other mental and behavioural disorders of the PUERPERIM”.
I am presently helping an old age pensioner, who is not computer literate , who has been funding various PMB’s from her Medical Savings Account. Despite all her claims being submitted to her medical scheme with the correct PMB specific ICD10 Codes, these DO NOT set off a “trigger” at the scheme (a recommendation agreed to in the 2010 PMB Code of Conduct- you can google that document), and the accounts have been paid using funds in her medical savings account (in contravention of Regulation 10 (6) of the Medical Schemes Act). This is common practice. In the 2008/9 CMS report, one medical aid scheme had to refund members R9 million of claims paid from Medical savings accounts, and it was found that, overall, at least 20% of PMB claims were incorrectly paid. According to my research, nothing has changed since then.

My son was told by his doctor, after contracting tonsillitis twice this year and completing the course of antibiotics each time that he should book himself in for a tonsillectomy. He has had tonsillitis once before a few years previously.
When enquiring about cover for this operation from the medical aid, he was told that only after three events in a single year would an operation be covered.
Now I want to know how I can make an appointment to see the doctor/s / advisors for this medical aid as their doctors appear to be much cleverer than our family doctor. This is not the first time that they have refused to pay and draw on his savings account.
Seems the old adage “prevention is better than cure” is totally wrong and the medical aid whiz kids are the ones to consult. Possibly medical aids prefer to have you on your death bed before paying. I guess by then the chances of future claims are very much reduced.
I can understand how the pensioner Angela is assisting represents a wide cross section of medical members who appear to be being ripped off by these so called medical aids which cream over R1,700pm per member just to cover the cost of their cushy employment empires – if I remember the figure I read about somewhere correctly.
They are particularly adept at spinning their way out of most of their embarrassing acts and try to hide the fact that they appear to simply be money making rackets. I wonder how much is spent on legal and PR fees.

I would like to respond to this, but before I do, please note that I have a threefold interest in this article. First and foremost, I’m a consumer, secondly I’m a financial advisor specializing in medical aid schemes and medical short term products and, lastly I use to work for a medical aid scheme as a new business development consultant.

I’ve taken note of this article and have actually read and re-read it with great interest.

However, it is not 100% correct in its presentation or assumptions.

The very first thing that one must be aware of is exactly what a PMB is. The concept that there is a pre-determined list of ± 270 conditions for which your scheme must pay in full sounds great, but unfortunately, there are more to it than what meets the eye.

Yes, inclusive of the 25 common chronic diseases listed on the CHRONIC DESEASE LIST (CDL’s), there are an additional ± 270 conditions listed in the DIAGNOSIS TREATMENT PAIRS (DTP’s) section as PRESCRIBED MINIMUM BENEFITS (PMB’s) which, in total, with all of its sub-conditions, consists of a “mere” 158 spreadsheet pages. Yes, your medical aid must provide full cover for the diagnosis, treatment and care of these conditions. BUT, there are some things regarding the PMB’s and its benefits that the author of this article carefully (if not strategically) refrained from mentioning:-

1. Yes, it is prescribed, but the emphasis is, and will always be, on MINIMUM.
2. DTP’s and TREATMENT ALGORITHMS are determined by the World Health Organisation guidelines for appropriate outcome based treatments.
3. There are specific TREATMENT ALGORITHMS for each of these CDL’s.
4. The level of treatment in the DTP section is guided by the public healthcare protocols. Yip, the level of treatment that you are ENTITLED to is on par with that which a person without a medical aid is entitled to in any of our public hospitals. Why?? To protect the scheme against unnecessary (and often greatly overpriced) treatments.
5. Your service provider should know and understand these guidelines to ensure that you get the treatment you need for these conditions without incurring costs that your scheme doesn’t cover.
6. The Council for Medical Schemes (CMS) encourage medical aid schemes to enter into contracts with a DESIGNATED SERVICE PROVIDER (DSP’s). Some have contracted with private networks (i.e. hospitals, optometrists, dentists, etc.), but others are actually still making use of the public sector as their DSP. Taking this into consideration, you should consider yourself fortunate if your scheme have contracted with a private DSP.
7. The purpose of the DSP is to save the scheme unnecessary costs. Should a client chose to make use of a non-DSP, he/she may incur co-payments.
8. These co-payments will normally be equal to the difference between the actual costs and that which the scheme would’ve paid to the DSP. (1)
9. While a scheme may appoint a DSP in order to limit costs, full costs must be paid from any provider if it is an emergency. (2)

Side note 1: – As a rule, GAP cover products does not cover shortfalls on PMB related conditions.
Side note 2: – A medical emergency is termed as the sudden onset of a medical condition which is either life threatening or life altering and for which the patient needs medical intervention.

As a financial advisor, I obviously have a vested interest in the rights of my clients in terms of the Medical Schemes Act, 1998 (Act No. 131 of 1998), as well as the PMB’s as per Annexure A of the said act.

I have had this list in my possession since I started in this industry back in 2004. I have also, since then taken 7 cases to the CMS on behalf of clients. Four of which I’ve been able to conclude in the client’s favour. Two of which the CMS determined “nit-picking” from the client’s side and one in which I forced a well-known scheme (no, not Discovery) to change its unfair underwriting procedures. I’m currently busy with two more cases.

So, believe me when I say that the PMB’s in itself is not only a grey area, but it is also a highly debateable issue. But, to say that the information isn’t freely available is devoid of all truth. A call-centre agent may not have it on hand to send, but all of the schemes I deal with, will provide it on request, via e-mail. The Council for Medical Schemes (CMS) has not only published this list online, but have, at regular intervals, published a number of explanatory user guides regarding the PMB’s and its application.

But, the term “Ignorantia juris non excusat” or “ignorantia legis neminem excusat” (Latin for “ignorance of the law does not excuse” or “ignorance of the law excuses no one”) is as applicable within the medical aid realm as the term is applicable in the legislative one. In short, the client has an obligation to familiarise him- / herself with the terms, conditions, scheme protocols and rules of the product(s) that they have purchased.

Furthermore, it needs to be said that in more than one case, the service providers themselves are the biggest culprits in the ongoing PMB war. You can paint it any colour that you want, but the mere fact that you have a PMB related condition doesn’t mean that the medical aid scheme has an open chequebook. Just to recap on what I said earlier:-

“Your service provider should know and understand these guidelines to ensure that you get the treatment you need for these conditions without incurring costs that your scheme doesn’t cover.”

But, instead of sticking to these PMB rules, many of the service providers are quick in informing the client that their scheme is obliged to settle the costs in full (often in writing, on the pre-authorisation documentation), and then hike the price for their services. And yes, it actually happens.

Also see this very informative article regarding the possible future of PMB’s. (http://www.health24.com/…/Could-PMBs-be-on-the-way-out-2015…)

There are many facets to the PMB war, but one thing is for certain: – It is and will remain a minefield that will, in the end, blow up in all of our faces if it isn’t approached with great care.

https://www.facebook.com/medaidquote/posts/1045794922127633

Daniej, obviously, by your answer you assume that neither the journalist nor I understand what PMB’s ; Diagnostic Treatment Pairs or Designated Service Providers are. We do,completely. The article was specifically about non- disclosure, inaccessibility and lack of transpaprency of PMB’s. I don’t know of your personal experience as a consumer or broker, but mine and many people I am assisting ( for no financial gain whatsoever) have found that both the medical practitioners and the medical schemes are not forthcomming with information about PMB’s. As I reiterated in a response above, accessibility should include those members who are not computer literate, and many schemes’ brochures lack clear and easily understandable information on PMB’s. At the end of the article, my first 3 points of advice refer primarily to the medical practitioner’s ” duty” to inform the patient that they have a PMB, and what treatment OPTIONS are available INCLUDING out of hospital treatment ; that these medical practitioners need to correctly complete the required PMB / chronic application forms and also include the correct ICD10 Codes on all accounts, prescriptions , pathology and radiology accounts, so,that these are funded from the PMB risk pool.
Nowhere is it implied that members expect the schemes to have an open chequebook, in fact, the out of hospital benefits that are less favoured by medical practioners cost a fraction of a hospital admission, yet are far more difficult to secure. The PMB cover is also often less than the minimum provided in a state facility e.g. In the case of Major Depression the State protocol includes diagnostic tests (blood tests) to exclude an organic or medical cause of this illness. The medical schemes do not cover these tests at all if you choose the option of 15 out patient therapy sessions ( at a total cost of around R9000). However, these diagnostic tests are covered if you choose the 21 day hospital admission which, including therapy , costs in the region of
R98 000.
Many of the diagnostic treatment pairs are ambiguous and open to interpretation, again, in my view,making them inaccessible.
You say ” ignorance of the law does not excuse”.
However the Medical Schemes Act includes under unfair business practices: “Complex, legalistic and user-unfriendly information”.
I do have 17 years experience in the financial services industry myself, so feel that I am also qualified to speak on this subject.

I am a member of Bestmed and gave birth last year via C Section (had pre-eclampsia). I was left with a R3500 – odd Anesthesia bill that Bestmed did not cover. I called the doctors to make an arrangement, for them to inform me that pre-eclampsia is a PMB and Bestmed needs to cover it by law. I went back to Bestmed to find out why this isn’t the case, and they told me it is because the PMB code “was listed second on the bill and not first, according to policy”. Yeah right. If I haven’t called, Bestmed would have gleefully continued not paying and watched me fork out the money on top of the R5k I already pay them each month.

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