Top medical aids are breaking the law, risking lives, claim doctors
Discovery and GEMS deny wrongdoing as SAPPF asks the regulator to rein in alleged abuses
Patients' lives are often at risk because their medical aids refuse to pay for their treatment, says professor Chris Joseph, a member of the SA Private Practitioners Forum (SAPPF).
Joseph, an ear, neck and throat surgeon, is one of 3,500 private practice specialists who have complained to the medical aid regulator – the Council for Medical Schemes (CMS) – about SA’s two largest medical aids, Discovery Medical Scheme and Government Employee Medical Schemes (GEMS). The SAPPF claims the two medical aids are not paying for treatment they are legally obliged to.
The CMS is investigating Discovery and GEMS for allegedly not paying prescribed minimum benefits (PMB) – which are diseases for which treatment must be covered in full, but are subject to medical aid restrictions on the choice of drugs and procedures. The council announced what it called “inspections” of the schemes in its annual report in October.
As a result, the SAPFF asked its members for examples of claims that had not been paid in full or at all. It received 21,000 lines of unpaid claims in one week, representing every medical aid.
The sheer number of examples received in a short time is evidence that non-payment by medical aids was widespread, said SAPFF CEO Chris Archer in a letter to the regulator last week. The SAPPF complained that Discovery and GEMS found ways to circumvent paying in full for treatment of PMB diseases.
In some cases, SAPFF claimed Discovery and GEMS pay for PMB treatment out of day to day savings accounts – a claim Discovery Health and GEMS have denied.
The doctors claim GEMS defers patients to state hospitals for fully funded treatment of prescribed minimum benefits. Although legal, they felt this defeated the purpose of having a medical aid. GEMS did not respond to questions about this alleged practice.
Archer also maintained Discovery paid patients directly if above-tariff rates are charged – and often patients neglected to pay the doctors. The SAPFF urged the regulator to force medical aids to hold these patients criminally liable.
Doctors on Thursday met with the media in Johannesburg to explain the consequences of non-payment.
Joseph said the limitation of benefits has had fatal consequences. He cited the cases of two patients, a child and a 30-year-old, who died from head and neck cancers because their medical aids would not fund the high-cost treatment. Cancer is prescribed minimum benefit in law, he explained.
Specialist physician Adri Kok warned that medical aids were interfering in the doctor-patient relationship and limiting benefits more than before.
“We are sitting with patients that can’t be treated,” said Kok.
Ophthalmologist Mark Deist said medical aids had to let “doctors be doctors again”.
The SAPFF has asked the regulator to rein in both Discovery and GEMS for non-payment of legally required benefits.
“The SAPPF appreciates the opportunity to assist the CMS in this investigation and trust that the CMS will take note of the abundance of evidence of non-payment presented in the attached excel spreadsheet, as well as the general concerns contained in this written submission.”
Discovery Health CEO Jonathan Broomberg denied the claims. “Discovery Health and all its client medical schemes comply fully with all applicable PMB legislation," he said in response to questions from Times Select.
Discovery used specific doctors to keep costs down, said Broomberg. (However Joseph felt the best and most qualified specialists were not always on this list.)
Broomberg said: “We have a wide range of designated service provider networks in place to ensure that members can access their PMB entitlements across all professional disciplines and in all parts of the country.”
He said Discovery frequently met with doctors to discuss payment and treatment issues.
GEMS said it did pay for prescribed minimum benefits as required and never used member savings accounts to do so. Its principal officer, Guni Goolab, said 71% of money spent by the scheme in 2017 – R120.6bn – was on PMBs.
Goolab said GEMS's higher spend on PMBs “demonstrates GEMS's commitment to the payment of PMBs”.
Both GEMS and Discovery said there were various interpretations of the law on how doctors should be paid for PMB diseases and what restrictions could be enforced.
Goolab said medical aids and doctors interpreted the law on how PMBs must be paid for and whether restrictions on treatments can be applied differently. “It is abundantly clear that current legislation does not make provision for all the various interpretations surrounding PMB claims and the practicalities of DSP arrangements.”
Goolab said it was awaiting the finalisation of the investigation by the Council for Medical Schemes.
CMS spokesperson Grace Khoza said it had received the letter and other information from the doctors, and is “currently processing this information internally”.
“The CMS will make use of all laws at its disposal to enforce compliance. However we can only provide full details on this once regulatory decisions have been communicated to the schemes.”