UPDATE 14/8/2013 A SECOND JUDGMENT AGAINST THE MEDICAL SCHEMES & BHF:
we were informed 36 hours ago by the Council for Medical Schemes that their Appeal Tribunal on 29 July 2013 refused the appeal by GEMS against the CMS Judgment of June 2012 , ie that Schemes have to pay members their due benefits for services by practitioners irrespective of PCNS registration.
Now, while the handful of schemes ( that have continued to defraud members of their benefits by illegally vilifying practitioners who refuse to pay BHF extortion money) consider their endless options to continue appealing, its up to the Media to publicise the lies of these Schemes and BHF,and force them to listen to their Regulator CMS and pay members due benefits, and stop defaming dissenting practitioners, CMS and BHF.
Its up to Practitioners and patients to join our protest, lodge complaints with CMS against schemes who continue this fraud and malpractice, who want to increasingly control and dictate the age-old doctor-patient relationship.
Schemes and the BHF will no doubt – to continue the status quo- fight back with their endless funds (the >R70 billion a year medical schemes premium income ) , continue to appeal the judgment endlessly and vilify the tiny group of dissenting practitioners who fight for pateints’ rights, as schemes have done for decades now. Only increasing proaction by patients for their and their choice of concered doctors will prevail.
2010 Dear PostMenopausal Woman/ older member,
Please note the reminder this month to medical aid patients from the commonest Hospital Plan: the Discovery Coastal Core benefits list (like the Council for Medical Schemes CMS) makes it clear that you are covered for PMBs Prescribed Minimum Benefits Chronic Illness Benefits. “You have cover for a list of (almost 300) chronic conditions. You have full cover for approved medicine on Discovery Health’s medicine list or up to a set monthly amount for medicine not on our list.”
This flatly contradicts the lies that patients are told when they contact their hospital plan schemes about such benefits- eg Discovery tells their members they have NO out of hospital benefits. Their ‘consultant’ – even when the member visits their head office in person- simply and deliberately with fraudulent intent omits to tell the member to read the rules, that all they have to do is get their doctor to complete the necessary prescribed application form to be registered for chronic illness benefit, be it for eg menopause or unipolar depression.
In the end, it is the members’ fault – caveat emptor. Open medical schemes and their umbrella BHF are simply clever money-making businesses run for maximum profit, for the welfare of the owners/directors, not the patient-members. This is the unblushing naked published mission of the Board of Health Funder BHF , a ruthless co-op representing less than half the medical scheme members in South Africa, “ to ensure that it is able to lobby government and other organisations effectively and to influence policy where necessary on behalf of the entire industry.” The BHF is in such chaos as a private company claiming to lead a giant >R60billion a year industry that it’s financial report for 2008 has not yet been published on it’s website.
But despite numerous complaints of fraud against the BHF on which the Regulator -the Council for Medical Schemes CMS -has repeatedly had to take action, – CMS has just re-awarded the BHF an R8.5million-a-year contract to run a Practice Code Numbering System PCNS . This cost is more than double that of the next bid of R3.5 million for a far better service. And the CMS without explanation simply declares “closed” numerous substantiated complaints ( by patients and their doctors) of blatant fraud against members by the BHF and it’s constituent medical schemes. Can this criminally wrong award action be due to anything but fraudulent collusion between the BHF and recently resigned chief executives of COMS and BHF? Otherwise why would there mysteriously be no obvious news announcements about this award on either the CMS or BHF websites, nor rebuttal of the accusations in the Medical Chronicle of early this month.
And why has the Statutory Regulator- the CMS- continued to allow despite regular complaints the lies on the BHF website eg “The practice number, allocated to all registered healthcare providers is a legal requirement for the process of reimbursement of a claim to a service provider.” This is NOT a legal requirement.
In fact elsewhere the BHF now publishes the truth: “In accordance with the Medical Schemes Act 131 of 1998, a medical scheme reimburses a member for services rendered by a provider of service duly registered or licensed with the relevant government.. statutory council.” Thus the medical scheme is contractually bound to reimburse the member for services by eg a doctor registered with the Heath Professionals Council of SA.
The Council for Medical schemes recently confirms to me in a letter (printed below) what their rules have stated for years, that obligatory benefits- which are paid for by the med scheme not from your benefits- include not just the 27 most common chronic major disease conditions but also eg :
*Menopause Disorder – 2 visits a year and appropriate HRT;
* and Chronic Depression including 15 psychotherapy visits a year and approved antidepressant- by a psychiatrist.
Thus if suffering from these two common conditions from mid life, you should have had completed a CIB form for menopause for 2 visits a year;
and you and a psychiatrist a CIB form for Depression.
Did you/we do so? For depression Have you seen a doctor the past 6 mo?
Check your Med aid website to see if you are registered for both conditions, with appropriate drugs.
If not, then you and your doctor do so. Neither your doctor nor your open medical scheme have any choice in the matter, obviously provided the diagnoses are genuine.
Your Med Scheme is apparently under no obligation to inform your doctor (completing the application form) of the outcome of your application EXCEPT in rejecting the doctor’s claim for services.
Current correspondence with CMS: (names are omitted as these statements emanate as offIcial policy statements sent me from the Benefit Management Unit: Clinical Analyst and via her from the acting CEO and Legal Head):
Dear Dr Burman
“The acting CEO requested that I provide you with detailed information with regards to our telephone conversation on Friday 15 January 2010.
It seems that there has been a misunderstanding with regards to the coding of PMB conditions and the registration of PMB conditions at medical schemes.
I would like to clarify the following matters:
1. PMB registration as discussed in Circular 37 of 2009 2. PMB ICD-10 coded list on the CMS website 3. Requirements of a PCNS number
1. PMB registration as discussed in Circular 37 of 2009
“On 15 December 2009 we published circular 37. The circular details the findings of:
- Evaluations of compliance with certain administration standards by medical schemes and third party administrators
- Analysis of numerous complaints received by the CMS.
“One of the findings was that medical schemes and third party administrators require members to register their PMB conditions with the scheme. This involves the completion of a registration form and also the submission of certain clinical criteria to the scheme. Benefits were only provided once the registration was completed. This requirement is not permitted as the PMBs are a legal entitlement as detailed in the Regulations to the Medical Schemes Act 131 of 1998.
2. PMB ICD-10 coded list on the CMS website
The CMS published a document i.e. Prescribed Minimum Benefits ICD 10 Five Character Coding – Excel Version 1.04 on our website on 4/8/2008.
During our conversation I mentioned that the list is not a legislative document and the intention was that it should be used as a basic guideline to link PMB conditions to specific ICD-10 codes.
Since this is not a legislative document but a basic guideline only, schemes should not use it as the final determining factor when deciding whether a condition qualifies as a PMB condition or not. The regulation is still the only legislative document.
PMBs consist of Diagnostic Treatment Pairs (DTP), Chronic Disease List (CDL) and Emergency Conditions.
Although PMBs are legal entitlements, certain criteria do exist in the regulation. Certain conditions e.g. Unipolar depression is included in the PMB DTP regulation but the treatment specified does not include medical management. The only treatment currently specified in the PMB regulation is Hospital-based management up to 3 weeks/year (including inpatient electro-convulsive therapy and inpatient psychotherapy) or outpatient psychotherapy of up to 15 contacts
The situation for the treatment of Bipolar Disorder did however change as the Minister of Health published the Bipolar Mood Disorder algorithm during December 2009. Medicine management as detailed on this algorithm is therefore now part of the entitlement of the condition.
Please remember that not all chronic illnesses are mentioned in the Chronic Disease List (CDL) but that a multitude of chronic illnesses are included in the Diagnostic Treatment Pairs (DTP).
Chronic conditions covered under the DTP list include for example Menopausal Management. The treatment specified for Menopausal management however details Medical and surgical management, including hormone replacement therapy.
This is the difference between Menopause and Unipolar Depression. Both are included in the PMB regulation under the DTP list but the treatment specified for each differs.
3. Requirements of a PCNS number
CMS obtained a legal opinion on the PCNS from Senior Counsel. Their opinion is that any provider wishing to receive direct reimbursement must obtain a PCN. Should they not do so then they are not disqualified from practising medicine or from treating scheme members, but are simply NOT entitled to demand direct payment. The PCN grants them an entitlement. Schemes may also not refuse to reimburse a member who has been treated by a provider not having a PCN, but may refuse to reimburse the provider directly on the basis of him or her not disposing of a PCN.
BHF unfortunately holds a view that medical schemes are not entitled to recognise a provider not having a PCN and may not pay any claim emanating from such provider. The legal opinion does not support this view.
We have published Circular 35 of 2007 that dealt with the specific problem (attached to this mail).
Please supply your members with a copy of the circular and request them to discuss their entitlements with the medical schemes in order to receive reimbursement for the services obtained from you.”
Benefit Management Unit: Clinical Analyst
THEN WHY IS CMS UNABLE TO EXPLAIN WHY AS THE STATUTORY REGULATOR IT IS UNABLE TO ENFORCE IT’S CIRCULAR 35 OF 2007 DESPITE IT”S UNEQUIVOCAL DUTY AND RIGHT UNDER THE ABOVE TERMS THAT THE CMS WEBSITE, CEO AND BENEFITS MANAGEMENT SET OUT ABOVE?.
WHAT IS THE POINT OF PROMOTING CIRCULAR 35 OF 2007 WHEN THE BHF and IT’S CONSTITUENT SCHEMES FLATLY REJECT IT? HOW CAN MEMBERS ARGUE WITH THEIR SCHEME WHEN CMS REFUSES TO ENFORCE CIRCULAR 35 OF 2007 WITH THE MANDATE OF PARLIAMENT THAT EMPOWERS CMS?