By: Saslha  11-11-2011

Sep 2 2008 10:19PM

Johannesburg - The Council for Medical Schemes (CMS) has expressed concern that some medical aids are failing to communicate with its members when they want to claim for out-of-pocket expenses - an action which could be fattening up medical schemes' profits.

The council says medical scheme members frustrated by the prolonged process of retrieving money for claims are giving up, resulting in medical schemes retaining extra money as they don't reimburse the claim.

Some medical scheme members are now being asked to pay for products and services from general practioners, specialists and pharmacies out of their own pockets and claim back money directly from their medical scheme afterwards.

Codes on the claims are sometimes incorrect, resulting in patients' claims being denied. In other instances, patients get given the runaround by the medical scheme to get the code from the medical service provider, who in turn says the member should go back to the medical aid.

"There are a lot of challenges - like instances where the provider hasn't received proper training and the claim gets rejected because codes aren't presented on claims," said the CMS's acting registrar, Patrick Matshidze.

The CMS' head of legal services, Craig Burton-Durham, said: "If they [the schemes] are doing this deliberately, then it amounts to a contravention of the Medical Schemes Act."

The codes, which were introduced in July 2005, were designed with the purpose of introducing efficiencies.

Burton-Durham said that regulation six of the act places an obligation on the medical scheme to inform both the member and the other party which the member made payment to.

Consumers losing out

If a member's claim gets rejected because of a code, or if a member fails to submit a claim, the result goes straight to the profits of medical schemes.

By the end of 2007, there were approximately 3.2m principal members in registered medical schemes and 4.3m dependants. This is a total 7.5m beneficiaries.

On an extremely conservative basis, where only R10 was not claimed and should have been by each member during 2007, R320m would go to the profits of medical schemes.

Up the R10 claim to a more realistic R100, which still remains conservative, then medical schemes would have gained R3.2bn in 2007.

The CMS said that members are paying out of their own pockets, they must ensure that the necessary codes are on the claim to avoid facing a prolonged process to retrieve the money from their scheme.

"If members pay out of their pockets, and they feel that they can't get any joy when making contact with the scheme while making a claim to get reimbursed, they must contact us," said Matshidze.

He said the council would respond within 30 days of the time of contact, as the law required them to do so.