Surgery: obese people pay more
DISCRIMINATION: MEDICAL SCHEME STANDS ACCUSED
Medical scheme accused of discrimination as obesity must be ‘clinically relevant’ for surcharge.
Obesity must be clinically relevant for surcharge to lawfully apply, says council.
Surgeons and anaesthetists are entitled to charge 50% more when operating on obese patients, irrespective of the surgery’s nature. This came to light in an appeal before the Council for Medical Schemes (CMS).
The elderly lady (Mrs X) accuses Spectramed of discriminating against fat people as it refuses to pay for obesity treatment or any related costs and procedures. Thus, the 50% surcharge is also excluded. Spectramed covers surgery on obese patients at a lower level than its other members, Mrs X says.
She had spinal fusion surgery this year. The 50% surcharge was levied by her orthopaedic surgeon (R16 903), neurosurgeon (R4 581) and an anaesthetist (R8 041). All the providers also charged more than Spectramed’s tariffs, so her total copayment for the operation and follow-up treatment topped R100 000.
In documents before the CMS, neither Spectramed nor the patient dispute medical professionals’ right to charge the 50% “modifier” above their normal fees.
Medcodelink’s Dalena Coetzee is, however, critical of this. She says medical professionals charge by citing codes representing a specific treatment and aren’t time-based.
The SA Medical Association has a policy that all new codes and code changes to the SA coding system have the US Current Procedural Terminology (CPT) coded in private hospitals.
Coetzee says the CPT provides for a “modifier” where surgeons may negotiate additional costs if they consider the normal costs inadequate (like time spent or complexity). The medical professional, however, must individually motivate for additional charges.
She says in SA the modifier 0018 provides for surgeons and anaesthetists to levy a 50% surcharge for all surgery on patients with a BMI over 35.
There’s no clinical basis for it being at a 50% level and no requirement for the medical professional to show any clinical basis for the surcharge in a specific case. It could therefore be charged on anything from abdominal surgery to an eye operation.
A CMS representative, however, told Moneyweb obesity must be clinically relevant for 0018 to lawfully apply.
More recently, anaesthetists added “physical status modifiers” to their codes, Coetzee says. These provide for five levels of additional costs where patients have pre-existing conditions that complicate surgery, including a BMI above 40, smoking and heavy drinking. Coetzee says medical schemes generally don’t pay “physical status modifier” costs.
In an earlier ruling, the Final Appeal Board rejected a protocol then applied by Spectramed and other schemes, which excluded payment for joint replacement surgery on obese patients as the protocol wasn’t evidence-based.
Mrs X argues Spectramed is trying to slip the same exclusion in relation to all surgery, via its Obesity Funding Policy. She says the policy isn’t in the scheme rules and the CMS wouldn’t approve it, as it’s discriminatory.
See Spectramed administrator Agility Health’s full response on moneyweb.co.za