The right prescription
Members must also know their rights
DETAILING THE INTERACTION between medical schemes, doctors, hospitals and other healthcare service providers leaves an overwhelming impression it’s a shark tank out there. Many players seem to be after their pound of flesh. Ethics takes a back seat.
It’s not limited to service providers. In the past we’ve listed cases where – mainly due to poor record keeping at some medical schemes – members try (often successfully) to claim benefits they aren’t entitled to. Sometimes they no longer belong to the medical scheme; other cases have fake dependants presenting themselves as spouses or children.
However, there’s much that can be done to make sure all parties concerned act ethically and in the best interests of the patient. The onus falls largely on medical scheme administrators.
Medical insurance is much more complex and claims are made much more frequently than in other types of insurance, says Dr James Arens, clinical operations executive of Pro Sano Medical Scheme. “The matter is further complicated by the presence of a third party – the service provider or hospital.”
Typically, the system should work like this: a member receives service from the healthcare providers or hospitals, which in turn submit the claims to the medical scheme for payment. “It would be naïve to assume all service providers will always be entirely honest in presenting their claims and that some members wouldn’t occasionally have the desire to maximise their benefits beyond what’s provided for,” Arens says.
He says the main duty of medical scheme managers is to ensure benefits are dispensed fairly and equitably among members. Further, they must limit abuse from service providers and make sure scheme members aren’t unduly exposed to unforeseen costs not covered by their benefits.
To meet those aims, medical schemes incorporate managed healthcare practices into their business, either as in-house or outsourced services. Arens lists the following as some examples and how they benefit (or are meant to benefit) members. Hospital pre-authorisation. The process whereby the service provider notifies the medical scheme of its intention to admit the patient and/or perform a medical procedure. The scheme has the opportunity to confirm available benefits and issue relevant disclaimers, as well as scrutinise diagnostic and procedure codes and fees submitted by the service providers. Arens advises members to also personally call the scheme to get first-hand information regarding disclaimers.
Here’s a new point members should note: Arens says the Health Professional Council of South Africa recently scrapped ethical tariffs – the fees healthcare service providers could charge above the reference price list (RPL) tariffs. Now the council rules that doctors charging above RPL rates need to discuss their fee with the patient and obtain written consent, in which case the member will be liable for the excess.
The moral for members seems to be: don’t sign until you’re quite happy with excess fees being charged. Like so many things in life, medical fees can be negotiated. Case management. Case managers are highly trained, registered nurses working for the scheme. They engage with hospital managers and doctors during hospital admissions to ensure the appropriate level of care and length of stay. The case managers also check that members aren’t subjected to out-of-pocket payments from unauthorised procedures while in hospital. Chronic medicines authorisation. A doctor who intends putting a patient on chronic medication needs to submit a request to the scheme. That will generally be approved by the scheme according to its medicines formulary. Arens notes schemes will often approve a prescription falling outside its formulary if the doctor submits a letter motivating why the patient needs the particular medication. Clinical protocols. Schemes may have a set of guidelines governing the manner in which certain diseases ought to be treated. The idea is that there’s consensus in the manner the doctor diagnoses and treats the member. The protocols are also meant to ensure cost-effective treatment. Underwriting. Meant to protect the pooled benefits of existing members by ensuring new members with existing conditions contribute to the pool for at least one year before they can claim for those conditions. Naturally, many of these managed healthcare services are provided by third parties charging fees. Arens urges schemes to evaluate such services carefully before buying them, to make sure they produce the intended savings and that members aren’t unduly denied benefits in the process.
“Managed healthcare interventions – when properly implemented and audited – can reduce costs by confining the practitioner to evidence-based medical practice and hence limiting abuse of benefits.”
Reduce costs by limiting abuse. Dr James Arens