CMS inquiry told medical schemes ‘a law unto themselves’

CMS inquiry told medical schemes ‘a law unto themselves’

CMS inquiry told medical schemes ‘a law unto themselves’

AUGUST 7TH, 2019 A FOCUS, MEDICAL AIDS

Health Department deputy director-general Dr Anban Pillay told the Council for Medical Aid Schemes inquiry into allegations of racial profiling that there were “serious problems” with the medical scheme coding system currently used and that practitioners were being “unfairly treated”. The Health Funders Association told the inquiry that it was unable to say whether most doctors who got the codes wrong did so with, or without, an intent to commit fraud.

The Health Department called for a market inquiry into pricing and coding for medical procedures to stop erroneous claims from doctors that end up being rejected or perceived as fraudulent by medical aid schemes. According to a report in The Citizen, Pillay, Health Department deputy director-general, admitted there were serious problems with the coding system currently used and that practitioners were being unfairly treated. Making his submission to the inquiry, he said they had to abandon their price referencing guide list a decade ago as practitioners rejected the tariffs. And when they were asked to submit their tariffs, it was discovered that they were hugely inflated.

“Basically, practitioners billed whatever they felt was right and medical schemes, for budgeting purposes, took the reference pricing list that was published, used CPI (consumer price index) for coding. There is a code and there is a procedure. If you put in the code and it does not link to a procedure, they reject it,” Pillay said.

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https://www.medicalbrief.co.za/archives/cms-inquiry-told-medical-schemes-law-unto/