South Africa – PMBs: Liberty Medical Scheme obliges, but costs remain cause for concern

19 June 2012 – Acknowledging the importance of the provision of the set of Prescribed Minimum Benefits (PMBs) to its members, as intended by the Regulator, Liberty Medical Scheme (LMS) meticulously gives effect to the provisions of the Act. Irrespective of what a provider charges for services rendered, a medical scheme is obliged to pay in full, provided the services fall under the 300 medical conditions listed under PMBs, including 27 chronic conditions.

Andrew Edwards, Executive Principal Officer, Liberty Medical Scheme

Andrew Edwards, Executive Principal Officer, Liberty Medical Scheme

“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,” says LMS Executive Principal Officer, Andrew Edwards.

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, may well point to a degree of abuse, he adds.

“While the dismissal by the High Court of the application by the Board of Healthcare Funders (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,” Edwards stresses.

“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,” concludes Edwards.