Londiwe Buthelezi: Business Report
PROFMED’S 25 000 members and their 63 000 dependants are unwitting pawns in a battle of wills between the medical scheme and the Council for Medical Schemes (CMS) over the payment of prescribed minimum benefits (PMBs) “in full”.
The CMS has threatened to deregister Profmed, which is contesting the regulator’s interpretation of “pay in full”. This comes even after the North Gauteng High Court recently threw out a challenge by the Board of Healthcare Funders (BHF) of the CMS’s view that schemes must pay for PMB treatment at the full invoiced amount and not at schemes’ scale of tariffs.
The restricted scheme for graduate professionals wrote to the CMS last week asking it to “immediately desist from any threatened deregistration proceeding relating to the scheme”.
Profmed submitted to paying PMBs in full but said it would persist in its appeal against the regulator’s demand that medical schemes must pay whatever health-care providers charged to treat PMB conditions.
“The board of Profmed has had to take this threat into consideration and, therefore, despite its continuing belief, based upon legal advice received, that CMS is incorrect in this matter and that Profmed is entitled to pay benefits in terms of its rules and not at full invoice, the board cannot take the risk that the schemes could be deregistered, or could even face deregistration proceedings,” Profmed chief executive and principal officer Graham Anderson wrote to CMS.
But Monwabisi Gantsho, the CMS chief executive and registrar of medical schemes, said the group would not stop its quest until Profmed acknowledged its interpretation.
“My response is that we cannot give any undertakings along the lines (Profmed) request since they have not withdrawn their appeal,” Gantsho said.
Anderson said Profmed was enduring reputational harm and thus needed urgent confirmation from the regulator that it would stop any deregistration proceedings.
Anderson assumed it was Profmed that the registrar said faced a threat of deregistration because of the notice the group was served to pay in full.
“We were not served with a deregistration notice but we could see it was us because we had already received an instruction to pay in full, which we have appealed,” Anderson said.
Profmed lodged an appeal two months ago against the CMS instruction under section 50 of the Medical Schemes Act.
“In other words, Profmed is prepared to conduct itself in accordance with the interpretation of the CMS on regulation 8 until such time as the appeal board or a court finds that such interpretation is incorrect. All payments made in the interim are made under protest.
“He (the registrar) is wrong in his assumption and interpretation. We can’t abide by this interpretation because it is going to make medical aid unaffordable,” said Anderson.
He said if the CMS decided to continue with the deregistration proceedings, the scheme would “deal with it as it comes”.
The chief executive of the BHF, Humphrey Zokufa, said the fact that the board did not get an interpretation of “pay in full” from the court meant that the matter was not yet decided.
“It’s unfortunate that we never got the judgment. What he (the registrar) is doing now is enforcing his own version, which is not the correct interpretation,” he said.
Zokufa said the BHF, which represents 95 percent of schemes, was “watching this space” because in time, service providers would increase their charges and schemes would just raise member contributions.
“It is superficial. At the front end it looks like it is going to protect the consumer but at the back end consumers are not protected. Over time it will force schemes to close down or fail to reach the minimum reserves. What this enforcement does is enrich the providers at the expense of consumers,” he said.
Zokufa wanted service providers’ prices to be regulated and then the BHF would not protest paying in full. - Business Watch, page 18
