Sep 2 2008 10:19PM
Johannesburg - The Council for
Medical Schemes (CMS) has expressed
concern that some medical aids are
failing to communicate with its
members when they want to claim for
out-of-pocket expenses - an action
which could be fattening up medical
schemes' profits.
The council says medical scheme
members frustrated by the prolonged
process of retrieving money for
claims are giving up, resulting in
medical schemes retaining extra
money as they don't reimburse the
claim.
Some medical scheme members are now
being asked to pay for products and
services from general practioners,
specialists and pharmacies out of
their own pockets and claim back
money directly from their medical
scheme afterwards.
Codes on the claims are sometimes
incorrect, resulting in patients'
claims being denied. In other
instances, patients get given the
runaround by the medical scheme to
get the code from the medical
service provider, who in turn says
the member should go back to the
medical aid.
"There are a lot of challenges -
like instances where the provider
hasn't received proper training and
the claim gets rejected because
codes aren't presented on claims,"
said the CMS's acting registrar,
Patrick Matshidze.
The CMS' head of legal services,
Craig Burton-Durham, said: "If they
[the schemes] are doing this
deliberately, then it amounts to a
contravention of the Medical Schemes
Act."
The codes, which were introduced in
July 2005, were designed with the
purpose of introducing efficiencies.
Burton-Durham said that regulation
six of the act places an obligation
on the medical scheme to inform both
the member and the other party which
the member made payment to.
Consumers losing out
If a member's claim gets rejected
because of a code, or if a member
fails to submit a claim, the result
goes straight to the profits of
medical schemes.
By the end of 2007, there were
approximately 3.2m principal members
in registered medical schemes and
4.3m dependants. This is a total
7.5m beneficiaries.
On an extremely conservative basis,
where only R10 was not claimed and
should have been by each member
during 2007, R320m would go to the
profits of medical schemes.
Up the R10 claim to a more realistic
R100, which still remains
conservative, then medical schemes
would have gained R3.2bn in 2007.
The CMS said that members are paying
out of their own pockets, they must
ensure that the necessary codes are
on the claim to avoid facing a
prolonged process to retrieve the
money from their scheme.
"If members pay out of their
pockets, and they feel that they
can't get any joy when making
contact with the scheme while making
a claim to get reimbursed, they must
contact us," said Matshidze.
He said the council would respond
within 30 days of the time of
contact, as the law required them to
do so.
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