Liberty Medical Scheme (LMS) today raised concerns about the potential for abuse of costs on prescribed minimum benefits. “LMS has our members’ best interests at heart. LMS obliges and pays claims for PMBs at the full rate charged by the doctor or other healthcare providers so that members are not held liable for any part of the bill. However, in the absence of guideline tariffs, the situation is potentially open to exploitation,” said LMS executive principal officer, Andrew Edwards.
He added that while it’s not easy to determine PMB abuse, scheme incidences of inconsistent billing patterns, higher fees charged for PMB conditions than for non-PMB conditions, a difference in hospital and specialist diagnoses and the deliberate charging of ICD 10-coding to benefit from PMB reimbursement protocols could point to a degree of abuse.
LMS said it acknowledged the importance of the provision of PMBs for members but called for a solution on pricing. “In terms of PMBs and the associated costs for medical schemes, a solution on pricing urgently needs to be found. This means the Competition Commission ruling banning medical schemes and provider groups from negotiating tariffs would have to be revisited. The sooner this happens, the sooner provider groups and funders can constructively engage, which will hopefully result in a compromise and win-win situation for all,” said Edwards.
In May this year the High Court denied the Board of Healthcare Funders (BHF) leave to appeal against its ruling that it had no right to ask the courts to clarify the meaning of regulation 8, a controversial rule that deals with medical schemes' liabilities for paying claims for prescribed minimum benefits.
“While the dismissal by the High Court of the application by the BHF to have PMBs reimbursed at medical scheme rates as opposed to at cost, may be hailed as a victory for consumers and the Regulator, this was merely dismissed on some technical issues. The absence of any guideline tariffs may ultimately be to the detriment of the very same consumers (due the elevated charges by a percentage of providers) who will end up footing the bill as a result of this interpretation as medical schemes need to balance claims paid against the contributions made by members,” added Edwards.