The right pre­scrip­tion

Mem­bers must also know their rights

Finweek English Edition - - Creating Wealth - SHAUN HAR­RIS shaunh@fin­week.co.za

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

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