Speaking at the Board of Healthcare Funders conference in Cape Town on Wednesday, Mark Hyman, chief executive of Medicheck, said fraud and abuse was being perpetrated by medical schemes failing to pay out Prescribed Minimum Benefits (PMBs) to members.

By law, medical schemes are bound to pay for costs related to 271 conditions and 26 chronic conditions that are classified as PMBs. Under the Medical Schemes Act, the PMBs include diseases such as tuberculosis and cancer while examples of chronic conditions that fall under PMBs include asthma, epilepsy and hypertension or high blood pressure. Medical expenses for these conditions are paid out from the scheme’s combined risk pool and not from your day-to-day benefits or your medical savings account.

The key provisions around the funding of PMBs by your medical scheme as per the Medical Schemes Act include:

• Benefit conditions must be paid in full, as per the invoice submitted by your healthcare provider such as your doctor, a specialist, or a hospital.
• Your scheme is not allowed to use your personal medical savings account to pay for benefit conditions.
• Your scheme is entitled to nominate a designated service provider such as a doctor, pharmacy, or hospital as the ­first-choice provider when you need treatment or care for the benefit’s condition. Read the fine print on your medical scheme documents. If a DSP is provided for under the option you choose, and you then choose to use a doctor or hospital that is not a DSP, you may end up having to pay a hefty co-payment. If it is an emergency and you have no choice but to use the nearest provider, the scheme may make an exception for this but will request proof that it was, in fact, a medical emergency.
• You usually have to register a chronic PMB condition with your medical scheme before your costs are paid as a PMB benefit. Jeremy Yatt, principal officer of Fedhealth says you would typically have to submit information such as the name of your doctor, the doctor’s practice number, the correct diagnosis or ICD-10 code, the name of the medication you require, the strength of the medication and the directions for use — how much medication you need in a single dose and how often you should be taking it.

Hyman says some of the problems around the non-payment of PMBs include doctors not providing proper referrals or diagnostic codes (ICD-10 codes). “For example, doctors should be writing down ICD-10 codes next to line items on their prescriptions, particularly when that information is needed by pharmacists or pathologists,” he says.

Pharmacists may not make a medical diagnosis or assign ICD-10 codes to a claim, which means members experience severe difficulty in getting their scripts funded correctly if a default code is used by the pharmacist. BM/DM