Even where there was overwhelming evidence that medical schemes had delayed in settling accounts, some schemes resisted paying interest accumulated if the member had been handed over to debt collectors.

The issue of interest levied on unpaid accounts was reviewed against the schemes’ rules, which exclude payments of interest on accounts, but payment had to be made due to late payment by medical schemes

Source Council for Medical Schemes Annual Report 2019/2020 Page 158

Medical Aids (specifically) Polmed’s and GEMS’ letters of authorisation contain a lot of irrelevant information not closely related to the procedure or reason requested for authorisation.

To illustrate: Authorisation for oncology benefits will include information about funding breast reduction.

In other words, the important facts for the purposes of complaints investigation are clouded by irrelevant information in authorisation letters.

GEMS failed to provide members with adequate information at pre-authorisation stage regarding skin lesion removal.

GEMS would approve the procedure but fail to inform the member that there is a limitation on the number of lesions removed at a time, for example, that it authorises 10 lesions at a time.

A member would then have 70 lesions removed and the scheme would fund only 10 removed lesions.

The Registrar of Medical Schemes ruled in favour of the complainants as the scheme failed to provide members with the full extent of cover, despite having knowledge of the number of lesions that were planned to be removed surgically.

Source Council for Medical Schemes Annual Report 2019/2020 Page 158

It is common cause that an ICD-10 code on its own does not validate PMB status of an account.

It is also generally acceptable for medical schemes to structure PMBs in the form of a basket of care (BoC) considering its protocols and formularies.

However, there is a tendency to short-fund even clear-cut PMB/emergency claims in the medical schemes industry across the board, which contradicts the provisions as prescribed by the Medical Schemes Act 131 of 1998.

Medical schemes and their administrators neglect to act in the best interests of members in taking the time to investigate internal complaints received, or to explain, when contacted for clarity by members or healthcare providers, which clinical records/letters of motivation are required for them to review and correctly fund the claims.

They rarely go the extra mile to satisfy themselves that they have complied with their own PMB funding obligations in terms of the Act, and payment of the balance on the accounts was only triggered by complaints from the CMS

Source Council for Medical Schemes Annual Report 2019/2020 Page 159

A trend noted was in relation to false representation of non-PMB procedure co-payments by Medical Schemes

A CASE STUDY

A number of DISCOVERY HEALTH MEDICAL SCHEME complaints were received wherein beneficiaries were dissatisfied with the scheme’s marketing of procedure co-payments as a form of shared liability with DISCOVERY HEALTH MEDICAL SCHEME, whereas in reality, these were ostensibly used by DISCOVERY HEALTH MEDICAL SCHEME to completely avoid liability.

In these matters, we found that the scheme had standard co-payments in respect of certain endoscopic procedures that were priced above the actual procedure costs.

Although DISCOVERY HEALTH MEDICAL SCHEME had registered a rule that exonerated it from liability if the cost of service was equal to or less than the co-payment, the Council for Medical Schemes found that the scheme’s communication of these benefits was ambiguous, and funding restrictions were unfairly hidden from beneficiaries.

This resulted in beneficiaries unknowingly incurring more liability than they would have anticipated, in that they became liable for the entire procedure as the co-payments paid would exceed the amounts charged.

In M v DISCOVERY HEALTH MEDICAL SCHEME, the complainant and his son underwent in-hospital gastroscopies, for which he was advised that there would be a specified co-payment for each of them, which he accepted.

Following the two procedures, he learned that the entire hospital account was his responsibility due to the fact that the hospital account amounted to less than the co- payments.

The complainant was therefore aggrieved by what he saw as a manipulated marketing strategy sold as a co-payment when in fact members were expected to pay in full, out of pocket (OOP)

Following investigation by the Complaints Adjudication unit of the Council for Medical Schemes, an unfairness in the practical implementation of the scheme rules and in the way the scheme communicated and marketed some of the procedure co-payments was found to be the case.

Whilst the relevant rule was registered and binding, it was not made clear to beneficiaries that should the cost of the procedure be equivalent to or less than the co-payment, the scheme will not pay anything towards that service unless a PMB (Prescribed Minimum Benefit) diagnosis was made.

This was equivalent to no benefit at all and it was misleading to market these endoscopic procedures as covered benefits when they were not.

Although the scheme had acted within its rules, its conduct was found to have been in bad faith by failing to disclose upfront that no funding will be made if the cost of the procedure was equal to or less than the co-payment charged.

Beneficiaries were essentially being deceived into believing that they were co-paying a service.

The scheme was directed to revise all benefit brochures and pre-authorisation communication to include clear and accurate outline of the extent of cover available to members whose procedures are subject to co-payments.

The scheme was further directed to ensure that all benefits and pre-authorisation correspondence contained clear and precise communication regarding the exclusions, particularly those involving deductibles/co-payments.

The CMS’ view remains that rules and restrictions which may result in adverse financial impact must be clearly and visibly communicated.

DISCOVERY HEALTH MEDICAL SCHEME eventually acknowledged this shortcoming and undertook to revise its benefits and pre-authorisation communication accordingly

Source Council for Medical Schemes Annual Report 2019/2020 Page 154