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Mediclinic News : Medical scheme body told to give more details

Title

Medical scheme body told to give more details

Date

2017-04-25

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News Description

BUSINESS DAY The Competition Tribunal has ordered the Council for Medical Schemes (CMS) to submit further details and consolidate its case against the South African Medical Association (Sama) in a long battle over how specialists bill patients. The matter potentially has far reaching implications for the way medical schemes reimburse patients, as Sama is the biggest doctor organisation and holds sway across the industry. The dispute between the parties dates back to 2013 and centres on the CMS’s allegation that Sama has engaged in a prohibited horizontal practice by endorsing the billing practices of the South African Paediatric Association (Sapa) and the Society for Cardiothoracic Surgeons in SA (SOCTSA), thus breaching the Competition Act. These associations use extra billing codes that are not included in the National Health Reference Price List (NHRPL), published by the CMS more than 10 years ago. While the NHRPL codes and prices are not legally binding, many medical schemes use them to set reimbursement levels for patients and will not pay for codes that are not in the NHRPL. Doctors say the NHRPL codes are outdated and fail to reflect current practice. The CMS alleged Sama’s 2009 tariffs allowed paediatricians to bill an extra 50 percent above the NHRPL rate for newborn babies that needed intensive care. It also complained about the 2010 billing guidelines published by SOCTSA. Sama asked the tribunal for an order in March to dismiss the council’s complaints or force it to provide more details of the allegations of price-fixing it made against the associations. On Monday, the tribunal dismissed Sama’s application to have the matter dismissed, but gave the CMS 20 days to consolidate their pleadings in connection with the two complaints it lodged in July 2013. The tribunal said the 2013 referrals have evolved and such evolution has given rise to confusions and contradictions. It ordered the CMS to elaborate on the binding nature of Sama’s publications, why it is important for Sama to publish them, and how it achieves compliance by paediatric specialists. The tribunal said the CMS needs to outline what mechanisms, if any, are used by Sama to punish non-compliance. CMS spokeswoman Elsabe Conradie said Sama had requested another statement, which it was working on.
Created at 2017/05/03 04:53 PM by Mediclinic
Last modified at 2017/05/03 04:53 PM by Mediclinic