Battle over medical aid benefits

2010-12-14 10:14

IF YOU are a member of medical scheme, you may need to take note of what's happening in the courts.

An estimated hike of almost 20% in your medical aid tariffs may be at stake.

The legal tussle between the medical schemes on one side and the authorities, hospitals and other healthcare providers on the other focuses on prescribed minimum benefits (PMBs).

PMBs are conditions that medical schemes are legally obliged to cover. These include any emergency condition (for instance, if you need life-saving surgery after an accident) as well as 26 chronic diseases like asthma, diabetes, epilepsy and HIV/Aids.

While most medical schemes cover the treatment costs of these conditions in full, some have started to pay up to a certain level, as stated in the rules of the scheme.

Some industry representatives say PMB bills have rocketed because hospitals and other healthcare providers know schemes are obliged to pay for these treatments.

The Council for Medical Schemes (CMS) has now taken legal action to oblige all medical aids settle all the medical bills for these conditions. The law says these treatments have to be covered "in full".

In reaction, the Board of Healthcare Funders (BHF), which represents the medical aids, has taken the matter to court, claiming that "in full" means that the schemes have to pay out the level of coverage provided for in their own rules.

The Johannesburg High Court recently postponed the case after a number of other parties – including organisations representing medical specialists and pharmacists, as well as Medi Clinic - asked to intervene in the case.

Medi-Clinic ignored a request for comment and CMS spokesperson Aleksandra Serwa said that the matter is sub judice and her organisation cannot get into the merits of the case at this stage.

"Just to point out, the Medical Schemes Act has not changed and provisions on the prescribed minimum benefits have not changed either. Medical schemes must cover PMB conditions in full – this is the law," she added.

But Heidi Kruger of the BHF contests this and says that such an interpretation will hurt already vulnerable medical schemes and their members.

According to conservative estimates, the move could mean a 20% hike in medical claims, which will push up member contributions by more than 18%.

Some medical scheme industry members claim that hospitals and healthcare providers are hiking the costs of PMB treatments because they know the schemes are obliged to pay.

There is currently no limit on what medical practitioners and hospitals can charge.

Specialists who have no heart

Government's reference price list (RPL), which basically set a guideline base price for treatments, was scrapped in July. The Health Professions Council of South Africa used to have an "ethical price list", which set maximum rates (roughly three times the RPL), but it has also now been abolished.

Healthcare providers are now able to charge any outlandish amount, and medical schemes will have to pay it, she says. The result of this is an open-ended liability for medical schemes and their members, says Kruger.

This is a particular problem with specialists. There is a huge shortage of specialists, with long waiting lists, and they can basically charge what they want.

One of the priciest PMBs is emergency treatment for heart attacks and strokes. Triple bypass surgery can cost up to R150 000.

Len Deacon, principal officer of the TopMed medical scheme and board member of BHF, says that the viability of medical schemes is being threatened.
According to the Council for Medical Scheme's latest annual report, medical schemes are already paying out R2.5bn more than they get in from contributions, which could have a knock-on effect for members.

"Given that there are no ceiling prices on treatments, the financial impact of paying rising PMBs at whatever the provider wishes puts the member and the medical scheme at risk, which is why clarity is needed."

But Serwa says there is no evidence to support allegations that member contributions will have to be hiked, and that schemes will be threatened.

"The Council for Medical Schemes has in fact been asking for this evidence for the last few years."

A date for the new court hearing is expected to be set in the first quarter of 2011.

 - Fin24

  • Medical Aid Scum - 2010-12-14 10:29

    To be fair here, hospitals and doctors can essentially charge what they want. This has been going on for years, and at some point it has to stop. Medical aids can not pay infinite sums of money. The same is happening with medication. Medical aids are pushing for more generic medication because the non generic pricing is out of control. Where does it stop? There needs to be limits set on PMB's and hospitals and Doctors need to be reigned in.

  • rick - 2010-12-14 11:13

    the medical fraternity sees medical aids a a huge cash pile. hence the outlandish prices charged - both by hospitals and doctors. the only solution is to stop medical aids. Watch the doctors and hospitals squeal !!

  • Dean - 2010-12-14 11:31

    Once again greed rears it's ugly head. I've been a staunch capitalist my whole life, but scenarios like the sub-prime lending debacle, and this really make me wonder......

  • SSTEF - 2010-12-14 12:03

    Remember Medical schemes any way only pay medical aid rates and the client pay the difference, so no harm to medical aids only us clients gets screwed by this high fees from doctors.

  • Thato - 2010-12-14 12:12

    It's just business.

  • Joeman - 2010-12-14 12:19

    I pay R3500 a monthly and after consulting a specialist doctor for examinations in a period of six days, my savings were exhausted. This is the only time I have consulted a doctor in the whole year for a family of four. I vote for the scrapping of the medical aids, at the least change the medical benefit as non-compulsory benefit. This health insurance is expensive, I won't mind the public hospital.

  • sunny - 2010-12-14 12:56

    No wonder we gonna get the new national health insurance's because of idiots and greed....

  • ET - 2010-12-14 12:59

    @ rick, the public will "squeal" if dr and hopsitals are not there.... count your words ! - that market forces are at work - the next eskom-like crisis looms. my solution, let the government put their money where their mouth are and get the public sector up to scratch ! - remember, healthcare is a bottomless pit....

  • Surgeon - 2010-12-14 13:06

    Being in the industry myself, this is a very subjective post. The time has come now that everybody in the industry has to start to protect the industry. It aggravates me when colleagues charge more than their usual fee just because they are treating a PMB condition. Saying that though, it must be made clear that there is no way that doctors can survive on being paid medical aid rates - if there is a fair compensation from the medical aid side, it wont be necessary for doctors to charge more than medical aid rates. I do agree with the medical aids though [although it pains me to do so], that if attention is not given to the PMB legislation, it will mean the end for private health care in South Africa. Medical aids will be priced out of the market for the average person and everybody will suffer due to this.

  • Steve - 2010-12-14 13:40

    One has to wonder if the government scrapping the RPL and allowing this to happen isn't all in aid of bankrupting the medical aids in preparation for forcing everyone onto the NHI. At which point they'll bring the RPL back and dictate exactly what they will be prepared to pay.

  • Dumbfounded - 2010-12-14 14:18

    Both the healthcare providers and the medical aid schemes are playing right into the governments pans. Espescially with the introduction of the NHI. There should be a limit to what healthcare providers can charge and clear guidelines to what medicals schemes will cover. Yes, the consumer will be the ones baring the brunt of this and espacially people in afluent areas where we already see this in a number of business sectors,e.g. a Steers burger in Boksburg will cost you R33 where in Sandton it is R38. The smae will apply to healthcare providers now that the maximu rate guidelines has been abolished. GREED - will be SA's downfall

  • Gynecologist - 2010-12-14 14:40

    I dont care you people must suffer and pay, I charge more than hollywood doctors and I line up my patiens and cut them open one by one, no natural birth for me, I must play golf 3 times a week and need my sleep, hey I would get away with that in Australia, that is why I love the ANC and South Africa - viva ANC viva lots of ceasars viva lots of money for meeeeeee !!!!!

  • Patient - 2010-12-14 14:44

    There are some exceptions, but the bulk of doctors are feeding like pigs on strawberries off the SA public. Their greed knows no bounds and just like the gyne's who cut cut cut to maximise profits, they are only focused on cash. there are exceptions of course but the vast majority of the best doctors and dentists have left the country. That is why we are left with the dregs...largly of course there are many excellent doctors as well.

  • healthy guy - 2010-12-14 14:55

    I'm thinking of canning my medical aid. If I need a triple bypass costing R150000, I'll fork it out of my own pocket - no problem, I have the necessary savings.

  • Jamo - 2010-12-14 15:05

    Don't forget, all of you slating the medical aids that it is *govt intervention* at the heart of it for two reasons 1. Forcing medical-aids to cover certain conditions with no limit allowed is allowing unlimited pricing 2. By making such a stuff-up of our education system and living environment that the skills we desperately need are being driven from the country. Read my lips- WE DO NOT HAVE ENOUGH DOCTORS IN THIS COUNTRY. No NHI or legislation is going to change that and where you have a critical shortage the price skyrockets. Basic economics.

  • dougalan - 2010-12-14 15:14

    Drug prices are way, way too expensive in SA. My wife and I exhausted our R18 000 medicine limit after 9 months this year. Then I found that the 2 drugs I was using for enlarged prostate (Proscar and Xatral) were alone costing us well over R1000 every month. I went onto Google, found the generics, ordered them from and now buy them at about ONE FIFTH of the local price. They come registered mail, made by recognised companies such as Cipla, and they work absolutely fine, never mind the scare stories about 'impurities' etc that the drug companies have been putting out to stop people doing this. We are truly being ripped off by high drug prices here - no wonder our medical aid bills are so high.

  • DrP - 2010-12-14 17:02

    @Surgeon: I charge only medical aid rates, and make a comfortable living. I can proudly say that I have never billed a patient above NHRPL, except by enhanced fees offered by medical aids for being a preferred provider. If I can do this AND employ 2 secretaries, a nurse, a cleaner, a gardener and pay a car, bond, rent, practice loan ETC. - so can you...

  • John - 2010-12-15 08:10

    It seems the entire system is spiraling out of control! I think Govt has seriously stuffed up a perfectly good system with their legislation. Another thing - everyone always bitches about medical costs, but what no-one seems to realize is that medical aids charge +/-R250 (if not more) just to adminster your funds. This fee is simply increased every year, without question, and without you even knowing it. Why not start complaining about that for a change.

  • The CMS Foe - 2010-12-15 09:27

    Re: "But Serwa says there is no evidence to support allegations that member contributions will have to be hiked, and that schemes will be threatened." Per the CMS own Annual Report 2009/10 the operating deficits of schemes in relation to the relevant healthcare expenditure on PMBs is documented. The last AR even has graphs indicating the ten year trend. The article has not mentioned the fact that the Health Minister Dr Aaron Motsoaledi supports the medical schemes in their bid. He is of the opinion in many public statements to the effect that "Regulation 8 should not be interpreted as giving healthcare service providers an open cheque book". The CMS has the ultimate role to protect medical scheme members and beneficiaries. At the moment they are part of a political plot at the whim of their new Registrar (a healthcare provider) to protect the interests of providers and advertently put medical schemes out of business. Consumers should be cautious. Yes, we would all like our medical bills satisfied in full, our monthly contributions are after all a grudge purchase but a purchase we nevertheless make as we want good private healthcare treatment and could only afford this through medical scheme membership. If medical schemes are out of business, could you afford private care out of pocket? Under NHI you would first contribute to the NHI Fund and then pay out of pocket for private healthcare if you so choose up until the time that Government has improved the NHI structure and services. You decide whether you are willing to do without a medical scheme indemnity insurance?

  • DAZED - 2010-12-15 10:20

    Dazed and confused 1.please look up Discovery's profit for the previous fin year - I rest my case 2.DrP - It has been showed by the University of Potch that it is impossible to run a GP practise on NHRPL (if you are not dishonest!)

  • Graham - 2010-12-15 10:40

    I have been told by my doctor to have a colonoscopy and booked an appointment with a Gastroenterologist who quoted me R7000 for it to be carried out in his rooms for which I would have to pay immediately afterwards. I realise that it is not a PMB so I checked with my medical aid and the rate they would pay would be R755.50. Whilst I believe that R755.50 is low, I believe that the Specialist is ripping me off by charging nearly 10 times the rate. I am prepared to pay a bit more but not in excess of R6000

  • Sandy - 2010-12-15 10:48

    Discovery do what the hell they like anyway , whether it is the law or not !!! If they dont like the law , they just chnage their rules ! Whilest I understand that limits have to be in place , like everything else in life, maybe they need to concentrate on being a medical aid and not a discount house !!! Has become a dictatorship of note !!

  • High Costs - 2010-12-15 11:14

    I agree with you 100% (MAS), doctors take advantage of the fact that the Medical Aid scheme's must pay the PMB conditions in full and charge whatever amount they see fit - some patients dont realise this, and just takes it for granted that the charges are justified - a limit needs to be set up in order to control costs, cause at the end of the day the members will have to fork up the money through paying higher contributions to pay for these higher costing bills.

  • Margaret @ DAZED - 2010-12-15 12:21

    Medical aids are, BY LAW, not for profit organisations. Do not confuse Discovery Health medical aid with the other profit generating companies within the Discovery stable, eg Vitality, Life, Card. Any operating profit made by a medical scheme remains within the scheme to boost the reserves. If PMB refunds are going to have no monetary restrictions then someone has to pay, and the only source of funds a medical aid has is its members.

  • Jakkals - 2010-12-15 13:44

    Yes, why not limit the fees a doctor can ask? Lawyers can be taken to bodies for charging excessive fees, why not get the health care profession also regulated?

  • John doe - 2010-12-15 13:45


  • Me - 2010-12-15 13:48

    My specialist charged me R750 for a 15 minute consultation paid in cash upfront. This was for the diagnosis of a chronic condition. He then charged another R350 just to fill out the medical aid forms, i.e. maybe 6 (six) lines. This is ridiculous greed!

  • em - 2010-12-15 15:57

    My fancy dentist claims that if i do not replace my amlagam filling with expensive fillings i will get alzheimers.He was going to charge R5000 per filling.Also he loves doing implants costing R20000 because plastic flase teeth are crap. He drive porsches,has a plane,a holiday home in the cape,a private plane,a mansion in kynsna and travels overseas 3 times a year

  • overseas doc - 2010-12-16 06:46

    the south african public does not appreciate the doctors that it has.. The average tradesperson charges more per hour, then the medical aid is willing to pay specialists. To add insult to injury, we then have to spend time explaining to patients why we charge co-payments. I would rather spend my time caring for patients and practicing medicine, then discussing fees. These issues are driving docs out. I am a superspecialist that wasn't appreciated here, and now am living the kind of life I want in an overseas country that appreciates its professionals.

  • Realist - 2010-12-16 13:38

    Medical aids are an expensive insurance policy for advanced technology which is not necessary in a majority of cases. Doctors bury their mistakes. Drug companies push addictive drugs and charge a fortune, and many doctors are complicit in the process. Lawyers protect them all. I trust none of them to look after my well being, they are only in it for the money. Go back to basics and take responsibility for your own health. Make the lifestyle choices to look after your own body.

  • DrP - 2010-12-16 21:58

    @Dazed: I'll be happy to forward financials to you. I won't get rich, but I do make a good living!

  • Gail - 2010-12-16 22:00

    Government ministers should lead by example and be made to go to National hospitals where they are at the mercy of too few doctors, nurses and even medications and procedures. Hospitals are not maintained and neither is the equipment and it is no wonder medical personnel are leaving. One needs to appreciate that training in the medical field takes 7 years and more which means that medical health providers have a shorter working life and hence the higher charges. @Gynaecologists - you confirm what many women suspect that caesarean sections are for your convenience. I gave birth to three children naturally and it was a doddle. Medical aids should look into their members who live at doctors and also use all their OTC allowances. Members should say they are private patients and see what a difference that makes, mention you are a pensioner etc. If cash is demanded up front then go elsewhere unless you have no choice. Death is inevitable and people should be prepared to go to Nat. hospitals as dying there costs nothing and the treatment is not necessarily any worse than private. Medical "accidents" happen at both private and national hospitals and in private they charge for every last sheet of toilet paper.

  • janvrot - 2010-12-16 22:32

    For sale, buy a Sefrican hospital bed for R1mil and earn R250k a year. The highest return in the world. For comparisoon USA = R100k pa, UK = R80k, SWitzerland = R60k. On the other hand our doctors can earn more overseas than here and droves have left the country. This is nuts.

  • janvrot - 2010-12-16 22:51

    lets go through the list of the richest people in SA. Owners of pharma manufacturers have shot to the top. You could too if you had the gutspa to import drugs from india for R2 and sell then to sick people for R16. Maybe you could con the taxpayer in paying twice as much for arv's compared to the rest of africa. But, its all worth it because they create jobs in the manufacturing industry for which they have received large tax deductions. Lets get real, the pills or api are imported mostly from india and these so called manufacturing plants are just glorified packaging plants. It is unbelievable to think that the cost of producing many drugs have halved over the last 2 years because of falling api prices and the strong zar. Over this same period our pharma manufacturers have received a 20% increase. How the SA economy functions is a mystery to me.

  • Bogi - 2010-12-21 15:40

    everone has a say about everything We live in SA where people know all about everything - no wonder we are still a 4th world country

  • JJR - 2011-01-07 14:17

    Uhm...R250 per visit @ 4 visits an hour is R173,040pm before VAT & 100% capacity (21.63 days a month, 8 hours a day). After VAT and at 70% capacity = R106,252pm. Less tax and overheads (2 secretaries, accountant, offices and nurse, etc.) = +-R20,000pm. Not that much considering...

  • Realist - 2011-03-17 15:48

    If the doctors falsify claims then they are committing fraud and should be exposed as fraudsters. Nothing wrong with medical aids auditing doctors claims, they are acting on behalf of the members who have to pay them.

  • Anke - 2012-03-22 08:35

    I am a physiotherapist and am shacked at what I'm reading! at our practice, we have been treating mainly patients with PMB conditions (e.g. strokes, traumatic brain injuries, chlidren with Cerebral palsy etc.) these people NEED therapy and are not getting it, because PMB is being shot down. i charge medical aid tariffs and even sometimes less than that, but am still not able to render a service to my clients because their PMB applications are being turned down one after the other! also, take note, that my overheads are approximately 50% of my monthy income... no, it is not easy being a service provider, but we camn do it with much dedication.

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