Prescribed Minimum Benefit

Prescribed Minimum Benefits (PMBs) are a set of defined benefits to ensure that all medical scheme members have access to certain minimum health services, regardless of the benefit option they have selected. The aim is to provide people with continuous care to improve their health and well-being and to make healthcare more affordable.

PMBs are a feature of the Medical Schemes Act, in terms of which medical schemes must cover the costs related to the diagnosis, treatment and care of:

·         any emergency medical condition;

·         a limited set of 271 medical conditions (defined in the Diagnosis Treatment Pairs); and

·         26 chronic conditions (defined in the Chronic Disease List).

The Medical Aid is required to cover the costs of the service even if they are more than what that scheme normally pays for the service

When deciding whether a condition is a PMB, the doctor should only look at the symptoms and not at any other factors, such as how the injury or condition was contracted. This approach is diagnosis based. Once the diagnosis has been made, the appropriate treatment and care is decided upon as well as where the patient should receive the treatment (at a hospital, as an outpatient or at a doctor’s rooms).

(reference = https://www.medicalschemes.co.za/resources/pmb/)

A Designated Service Provider (DSP) is a healthcare provider (doctor, pharmacist, hospital, etc) that is a medical scheme’s first choice when its members need diagnosis, treatment or care for a PMB condition.

A DSP doctor charges exactly what the medical aid normally pays for a service and there is no co-payment.

If you choose not to use the DSP selected by your scheme, you may have to pay a portion of the bill as a co-payment. This could either be a percentage co-payment or the difference between the DSP’s tariff and that charged by the provider you went to.

Medical schemes must ensure that it is easy for beneficiaries to get to the DSPs. If there is no DSP within reasonable distance of your work or home, then you can visit any provider and the scheme is obliged to pay.

When you suffer an emergency condition, or are involved in an accident, you may go to the nearest healthcare facility for treatment, even if it is not a DSP. Your scheme will have to cover the costs.

Schemes must also ensure that the DSPs of their choice can deliver the services needed and without members having to wait unreasonably long. Where a DSP is unable to accommodate or treat a member, the medical scheme remains liable for all the costs of treating the PMB condition at a non-DSP facility.

(reference = https://www.medicalschemes.co.za/resources/pmb/)

Discovery Health – executive and classic options

Remedi Health – classic options

Netcare Medical Aid – all options

Fedhealth – all options

Bonitas – all options except BonCap

Polmed – all options

There are a few other specialist anaesthesiologists working in the Pietermaritzburg area who are independent of Drs Jones, Bhagwan and Partners. These anaesthesiologists may or may not be DSPs of your scheme.

In is important to know the following:

- The DSP anaesthesiologist may not work with your specific surgeon

- The DSP anaesthesiologist may not be available on the day of your surgery due to other work, leave, illness, etc

- The DSP anaesthesiologist may not be skilled in your specific surgery or medical condition, for example: heart surgery, brain surgery, surgery on babies and small children, etc

- The DSP anaesthesiologist may not work after hours and so may not be preferentially used by certain surgeons

- The DSP anaesthesiologist may not cover the Intensive Care Unit and may not be used by surgeons whose patients require this level of post operative care

To our knowledge, other the Schemes listed above, there are no Medical Aids that have an adequate number of DSP specialist anaesthesiologists to cover all their DSP hospitals and their DSP surgeons 24 hours a day, every day of the year.

Certain medical aid schemes do consider public hospitals as designated service providers and can reject PMB claims on the basis that the patient should have attended one of these facilities for his / her surgery.

However, Drs Jones, Bhagwan and Partners frequently contests these cases on the basis of:

- The service not being available at the state hospitals in Pietermaritzburg

- There being unacceptable waiting periods for the service due to high patient volumes and limited resources

- In emergency situations the urgency of the treatment

An emergency medical condition means the sudden and, at the time, unexpected onset of a health condition that requires immediate medical treatment and/or an operation. If the treatment is not available, the emergency could result in weakened bodily functions, serious and lasting damage to organs, limbs or other body parts, or even death.

In an emergency it is not always possible to diagnose the condition before admitting the patient for treatment. However, if doctors suspect that the patient suffers from a condition that is covered by PMBs, the medical scheme has to approve treatment. Schemes may request that the diagnosis be confirmed with supporting evidence within a reasonable period of time.

(reference = https://www.medicalschemes.co.za/resources/pmb/)

Almost all medical aids DO NOT initially pay for PMB claims in full. The accounts are normally initially covered at the normal value that scheme pays for the service.

It is necessary to write a letter to the medical aid contesting the initial payment. The claim is then sent to the medical schemes “PMB Review Team”

The PMB Review Team may then require the following information:

-    A clinical letter of motivation written by the treating doctor confirming the PMB diagnosis

-    Supporting investigations, such as X rays, MRIs, CT scans, blood results, pathology results

-    A letter of motivation challenging the availability of another DSP anaesthesiologist in the private sector or challenging the availability of the service at the state hospitals.

In terms of regulation 15J(2)(c) under the Medical Schemes Act 131 of 1998, "a medical scheme is entitled to access any treatment record held by a managed health care organization or health care provider and other information pertaining to the diagnosis, treatment and health status of the beneficiary in terms of a contract entered into pursuant to regulation 15A, but such information may not be disclosed to any other person without the express consent of the beneficiary. This entitlement is subject to the prescribed requirements for disclosure of confidential information in terms of section 14 and 15 of the National Health Act 61 of 2003 and Ethical Rules of Conduct for Practitioners registered under the Health Professions Act, 1974 as published under Government Notice R717 in Government Gazette 29079 of 4 August 2006. Practitioners are therefore required by law to disclose or release the treatment records of their patients to the medical scheme without having to obtain the written consent of their patients."

Medical aids to have to comply with the Protection of Personal Information Act (POPI) to ensure that all the members’ personal and medical information is protected appropriately.

It is important to remember that the contractual agreement for medical treatment (in this case anaesthetic services or intensive care treatment) is between the doctor and the patient, and therefore payment of the account for such services is ultimately the responsibility of the patient.

It is also the patient who has a contractual agreement with the medical aid and therefore needs to communicate with the scheme to dispute payment issues.

Drs Jones, Bhagwan and Partners does, however, have well established procedures for contesting PMB disputes with most medical aids and can help you in this process at NO EXTRA CHARGE.

As described above this process usually involves submission to Scheme’s PMB Review Team the following information:

-    A clinical letter of motivation written by the treating doctor confirming the PMB diagnosis

-    Supporting investigations, such as X rays, MRIs, CT scans, blood results, pathology results

-    A letter of motivation challenging the availability of another DSP anaesthesiologist in the private sector or challenging the availability of the service at the state hospitals.

Please be aware that the consent form you signed at the time of the surgery / anaesthesia contained a clause that has given your consent to us submitting this information to the scheme on your behalf.

When a PMB dispute or claim is rejected by the scheme the shortfall owing on the account remains the responsibility of the patient, and payment is due within the time frame indicated on the consent form / contractual agreement, 30 days.

You can also contact the Counsel for Medical Schemes should you wish to contest your schemes decision:

https://www.medicalschemes.co.za

0861 123 267

information@medicalschemes.co.za

complaints@medicalschemes.co.za