Get the best possible treatment

As an oncology patient, you have loads of questions, especially when dealing with your medical aid to ensure the best possible treatment is covered. Campaigning for Cancer helps navigate this tricky terrain by explaining terminology and the meaning behind it and offers services to help attain the best possible treatment.

You can listen to this article below, or by using your favourite podcast player at pod.link/oncologybuddies

What is the ICD 10 code?

The International Classification of Diseases, Tenth (ICD-10 code) is a classifying and codifying system used by physicians across the world to make diagnoses, and the systems and claim procedures to medical schemes simple and easy. 

The National Health Information System of South Africa (NHISSA) has adopted this standard, so it’s used in both public and private healthcare.

ICD-10 coding translates diagnoses of diseases and other health-related problems from words to numbers and letters; the meaning of which everyone in the system understands. ICD 10 coding is used to record, analyse, interpret and compare morbidity and mortality data collected in the country and across countries. 

What are PMBs?

Prescribed minimum benefits (PMBs) are a set of defined benefits that ensure that every person has access to certain acceptable basic health services for a number of conditions or diseases, regardless of the medical aid plan they have selected or if receiving care in a public hospital.

PMBs ensure continuous healthcare coverage for PMB conditions. Even if your medical aid benefits have run out for the year, the medical scheme has to pay for the treatment for PMB conditions without penalty to you.

PMBs ensure that healthcare is paid for by the correct parties. If you have any PMB conditions, you’re entitled to the specified treatments, the costs of which must be covered by your medical scheme, or even if you receive care at a public hospital.

How do oncology benefits work in most medical schemes? 

Once your oncologist has diagnosed you, your treatment must be pre-authorised (this is essential). Your chosen medical scheme reviews the proposed treatment in line with registered scheme rules, protocols and formularies and provides a letter of authorisation. You’ll then go onto the scheme’s oncology programme and should familiarise yourself with the design of the oncology programme on your chosen plan.

Authorised cancer treatment is paid out of the oncology benefit, subject to scheme rules, normally over a 12-month cycle. Once the oncology benefit limit is reached, the medical scheme is obliged to cover the remainder of the treatment costs from the major risk pool, as long as the treatment in question is PMB level of care. Medical schemes aren’t allowed to cover PMBs from medical savings accounts.

NOTE: For more info about oncology benefits, you’re entitled to a copy of the most recently registered scheme rules, oncology benefits, protocols and formularies in terms of regulations 15H(b) and 15I(b), of the General Regulations to the Medical Schemes Act, 1998, as amended.

How do I know my scheme is paying out of the oncology benefit?

Your letter of authorisation detailing whether or not treatment has been approved should indicate that the treatment is approved for payment from an oncology benefit. If not, you must query this.

Have you been denied treatment or care by your medical aid?

Campaigning for Cancer, through our case managers, help patients and caregivers who have been denied or given limited access to treatment, benefits, medicine or healthcare. 

You have three options for lodging a case: via the online portal, email [email protected] or phone 082 224 4224.

Campaigning for Cancer’s advocacy services help cancer patients navigate their cancer journey, accessing treatment they are entitled to, whether they are being treated in a public hospital or belong to a medical scheme. They can advise you on how to deal with workplace situations arising from your cancer diagnosis, help you find credible information, and direct you to support services and aid in ensuring that you get the best possible treatment that you have the right to.