Medical schemes continue to fail to pay or short-pay members' claims for prescribed minimum benefits (PMBs), sparking almost half of all complaints to the medical schemes regulator. According to a Sunday Times report, the Council for Medical Schemes (CMS) says in its latest annual report that 1,242 of 3,808 complaints lodged last year related to PMBs – benefits that schemes are legally obliged to cover.
It also notes that some schemes are still using members' medical savings accounts, rather than scheme funds, to pay for the treatment of PMBs. The report says this is a contravention of the law, yet when picked out about it by the regulator the schemes concerned offered no explanation but merely advised that the relevant accounts had been reversed and reprocessed to pay from the scheme's risk benefit. The annual report states that this conduct shows more work needs to be done by the council to ensure full compliance by medical schemes and their administrators with the application of the law, "and that there must be consequences for those entities who contravene the (Medical Schemes) Act".
The health market inquiry has recommended that the coding of medical bills be regulated by a new regulator and noted that it is integral for a good payment system.
[link url="https://www.timeslive.co.za/sunday-times/business/2019-10-20-medical-schemes-short-changing-their-members/"]Sunday Times report[/link]