Medical schemes council signs blank cheque for doctors

SAMWUMED was ordered to pay a doctor three times its normal rate for emergency treatment of a member's dependant.

The bill was for a prescribed minimum benefit (PMB), in terms of which legislation stipulates that medical schemes pay costs on an unlimited basis. This was intended to protect members from out-of-pocket payments but legislation failed to indicate what the quantum of the tariff should be, creating a money-spinning opportunity for some healthcare providers.

Samwumed lodged the appeal against a CMS judgement in a complaint by an anaesthesiologist. After three months of deliberation, the appeal committee upheld the right of the doctor to charge whatever he liked. This despite an earlier ruling issued by the same committee in favour of a scheme in circumstances also involving emergency treatment that constituted a PMB.

Said Neil Nair, fund officer at Samwumed: “We lodged the appeal to properly challenge the notion that providers can take advantage of the system to enrich themselves at the expense of schemes and their members. The Council's judgement is surprising and inconsistent, not only with views expressed by the Registrar, but also with its own previous rulings on similar issues.

“Provision for full payment of PMBs is about guaranteeing access to healthcare, and not about providing a ‘blank cheque' to providers. In a dissenting ruling Advocate Ngulwana, chairperson of the appeal committee, provided insightful argument as to why he agrees with SAMWUMED. We regard access to healthcare as a social challenge of significant magnitude and intend taking this matter further, “said Nair.