What to do when liaising with your medical scheme

Elsabé Klinck gives advice on how to liaise with your medical scheme when various administrative and legal issues arise.

Approval of treatment plans

Doctors will talk to patients about the treatment options available to them. Once the patient has agreed to a specific plan of action, a treatment regime is developed, which will map out the course of treatment, how frequently treatment is to be received, in what form (e.g. by oral medication, and/or through infusions, etc.). The doctor will also discuss side effects, and possible treatment difficulties, and risks with the patient. 

In oncology, nearly all treatment plans must be recommended for approval by a managed care organisation, prior to being implemented. These managed care organisations are contracted by medical schemes to evaluate the care, and often operate in terms of lists of medicines, and specific treatment protocols. 

Treatments are tiered, i.e. persons on higher medical scheme plans might have more options. It must, however, be borne in mind that all PMB cancers must be funded in full, and the role of managed care will be discussed below.

It’s recommended that patients ask their doctors about these managed care processes, whether there are limitations on the available treatments for them and whether those limitations are right for them.

Even where one’s doctor is part of a managed care organisation, as most oncologists are, that doctor can express disagreement with the scheme, under regulation 15E of the Managed Care Regulations to the Medical Schemes Act. Neither the patient, nor the scheme should therefore hesitate to investigate, complain and/or appeal instances where the managed care or approved treatment plan would not be appropriate for the patient.

Motivating for success

It’s important that when motivating the following aspects be clearly set out in the motivation to the medical scheme, or managed care organisation:

• Whether the cancer is a PMB cancer , and if so, what the cancer’s PMB code and ICD10 code are;
• The patient’s condition, co-morbidities and specific factors that are relevant (e.g. age, previous remissions, etc.);
• If the patient had been on treatment before, whether that treatment worked, or not, and what the reason for that has been, attaching proof of, for example, side effects or adverse events, hospitalisation, etc.;
• Any contra-indication(s) to the scheme-listed treatment that would require an alternative treatment;
• The possibility of harm, or, if harm had already occurred, details thereof, should the scheme-recommended treatment be followed;
• Reference to the law, other cases that have been lodged and won at The Council for Medical Schemes (CMS) on similar principles (e.g. harm or treatment failure);
• The impact of the proposed care on the patient’s life expectancy, quality of life, ability to return to work, etc., or, conversely, the impact of not obtaining such care; and
• Indicate the time-sensitive nature of treatment, and the importance for the matter to be addressed soon, to prevent harm.

The law provides, in Regulations 15H (on treatment protocols) and 15I (on formularies, i.e. medicines lists), that exceptions must be made from the scheme, or managed care-recommended treatment, if that treatment cause, or would cause the patient harm, has been ineffective or caused the patient an adverse event (negative effect, such as a rash, etc.). In these cases, the patient is entitled to an appropriate alternative treatment, without any co-payment. 

Co-payments

Co-payments can’t be levied if the patient requires a different treatment to ensure effective care, or to prevent some negative event or harm. 

However, a co-payment may be levied if the patient would have been adequately treated on the scheme-recommended treatment, but decides to go for another treatment. 

The Council for Medical Scheme’s Managed Care Policy of 2003 states that all co-payments must be “reasonable”, i.e. close to the real difference in price between the two treatments that the patient chooses, and that the scheme wishes to reimburse. 

Patients must note that the same medicine costs the same, irrespective of where that medicine is obtained from. This same price for the same medicine is called the Single Exit Price (SEP), so no co-payment can be levied if the medicine is the same. 

There may be differences in the dispensing fee (the fee that the doctor’s pharmacy charges) but any co-payment should not affect the cost of the medicine to the patient, that should also be paid at SEP.

Complaints and appeals

Many medical schemes have an internal complaints process, where a decline for treatment can be addressed. The scheme’s decline must contain sufficient reasons, that relate to the law and their specific rules, to enable one to clearly understand why the proposed treatment is not funded. 

These reasons for decline, the initial motivation letter and the principles in law, such as whether the cancer is a PMB cancer, or whether one has proof of an adverse reaction, must all be addressed in a scheme complaint or appeal. It’s important that the doctor indicate why exactly a specific treatment is required.

If the internal processes are not successful, one can lodge a complaint at the Council for Medical Schemes, by sending a complaints form (available here: www.medicalschemes.com/files/Application%20Forms/ComplaintsForm.docx ), and all the supporting documents, such as the initial diagnosis, prescription, decline and follow-up letters, as annexures to the complaint, to: [email protected] 

One should get a complaint reference number within 48 hours, it will start with the letters: CMS and then numbers. This complaint number is the important reference to follow-up on the ruling, and to appeal, should the initial ruling not be in one’s favour.

Ex-gratia payments

Many oncology patients rely on ex-gratia payments (funding “out of good graces” by the scheme) to access the care they require. Although an option, one must remember that ex-gratia funding is a discretionary funding. It doesn’t give effect to any rights (e.g. the rights as set out above on treatment failure), and is limited to a certain period. It’s an honorary payment, and this discretion can be declined to be extended, at any time. This could mean that a patient is without cover in a subsequent treatment cycle, or in a new funding year. 

Don’t miss treatment because of lack of funding

When one takes up a motivation, complaint or an appeal process, delays in treatment may result. It’s important to talk to your doctor, and to see if accounts for treatment can’t be held in abeyance, pending the outcome of a complaint or appeal. 

In oncology treatments, delays often impacts on the effectiveness of the treatment, or your prognosis. Therefore, before skipping treatments due to funding challenges, discuss the matter with your doctor. 

It is also important to stress the time-sensitive nature of the treatment when complaining or appealing, making it clear that the matter is urgent. 

Conclusion

It’s important to understand the managed care frameworks around oncology treatment, and the rights you have as a patient in cases of treatment failure, adverse events or possible harm. These circumstances must be raised right from the very first motivation for treatment. 

One should also know when a co-payment can be levied, and what a lawful, and reasonable co-payment would be. Lastly, understanding the temporary and tentative nature of ex-gratia funding is important.