THE Council for Medical Schemes is to convene a high-stakes meeting today to try to resolve a row with the industry over the extent to which schemes are liable for members' claims for prescribed minimum benefits. The Medical Schemes Act says all medical schemes must provide all their members with cover for prescribed minimum benefits, a basic basket of care that includes emergency medical conditions, 270 diseases and 25 chronic conditions. In December last year, the council issued a strongly worded circular to the industry, saying many medical schemes were failing to comply with the Medical Schemes Act by refusing to pay for such benefits in full. Several schemes responded by saying they could not afford the open-ended liability punted by the council, and in the interests of all their members had to cap the level at which they would pay for such benefits. Most schemes set their threshold at a multiple of the controversial national health reference price list, leaving members to pay the difference if their doctor or service provider charged more than the rates set out in these guidelines. Many doctors and specialists charge above the reference price list rates because, they say, the recommended tariffs do not reflect the actual costs of running a practice. Today's meeting in Pretoria is expected to establish a task team that will work with the industry to draw up a binding code of conduct for handling prescribed minimum benefits claims. The stakes are high, as the council has threatened to deregister schemes or administrators that do not comply with the regulations on prescribed minimum benefits. At issue is how to interpret the regulations to the Medical Schemes Act that spell out medical schemes' duties regarding such benefits. Regulation 8 says all benefit options "must pay in full, without co-payment or the use of deductibles, the diagnosis, treatment and care costs of the prescribed minimum benefit conditions". The council says this means schemes are obliged to foot the bill for such benefits in their entirety, while many industry players say "in full" simply means to the maximum allowed by their own scheme rules. The industry also needs to figure out how to deal with a small minority of healthcare providers that abuse the loopholes in the system to charge very high rates, according to Boshoff Steenekamp from the council's strategic projects unit. He said that contrary to schemes' assertions that doctors routinely inflated their fees for prescribed minimum benefit conditions, the council had found no evidence that this was a widespread industry practice. Samwumed, which covers municipal workers, said the Medical Schemes Act's prescribed minimum benefit provisions should not be interpreted as a blank cheque. Samwumed principal officer Neil Nair said his scheme had been at the forefront of the battle for the past four years, challenging the council on the term "payment in full". He said it could never imply that a service provider could charge what he liked. Nair added that only about 10% of specialists were not adhering to scheme tariffs, but the fear was that this figure would increase in the future.

Tamar Kahn: Business Day, 11 May 2010