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Court bid to clarify medical aid benefits

Mar 30 2011 18:34 Sapa

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Johannesburg - The Board of Healthcare Funders of Southern Africa (BHF) will apply to the North Gauteng High Court in Pretoria this week for a declaratory order on the payment of prescribed minimum benefit (PMB) conditions, it said on Wednesday.

"We are arguing for the clarity of interpretation of the Medical Schemes Act on the payment of those conditions," said BHF spokesperson Heidi Kruger.

"We are concerned that doctors will charge as much as they can for these conditions and take benefit of the fact that schemes will pay that money out," she said.

PMBs are a mix of 271 hospital- and specialist-based conditions, 25 chronic conditions and all emergency medical treatment, which medical schemes have to cover under their benefit options.

The act states that a scheme has to "reimburse in full without co-payment or the use of deductibles" the diagnosis, treatment and care costs of PMB conditions.

Kruger said that the BHF was arguing for payment in full, based on the medical scheme's tariffs.

"This would prevent healthcare costs from becoming unaffordable."

BHF said a recent study of doctors' claims from January 2009 to July 2010 showed that doctors charged more if the reimbursement rate of a medical scheme was higher.

"This demonstrates to us that at least half of all healthcare service providers will charge as much as possible for PMBs if the scheme, and thereby the member, is forced to pay whatever is charged," BHF MD Humphrey Zokufa said.

He said that cost implications could be dire, given that 80% of a private hospital's income from medical schemes is for PMBs.

Kruger said that in the past two years, the healthcare service provider fraternity had successfully managed to remove all cost containment measures like the national health reference price list (NHRPL) and the Health Professions Council of SA ethical tariff list from the private healthcare environment.

The NHRPL was scrapped by the High Court in Pretoria last year, after it found that the process used to determine a standard set of rates was "unfair, unlawful, unreasonable and irrational".

As a result of this, and a profit motive, hospital costs had increased by over 75% in the past 10 years, and specialist costs by 59%, the BHF said.

In 2009/2010, claims paid out by medical schemes outweighed members' contributions by R2.5bn. Schemes were forced to dip into their reserves to pay claims as a result, the board said.

Kruger said the BHF would like the establishment of a proposed Pricing Negotiating Chamber so that tariffs paid were fair and reasonable to both the provider and medical scheme member.

"We sincerely hope that the courts will take this (unaffordable healthcare) into consideration when delivering their ruling," said Zokufa.

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