Private practice specialists have complained to the\u00a0Council for Medical Schemes (CMS) about South Africa’s two largest medical schemes – Discovery Medical Scheme and the Government Employee Medical Schemes (GEMS).<\/p>\n
According to a report by\u00a0 Times Select<\/a><\/strong>,\u00a0the South African Private Practitioners Forum (SAPPF) claims that the two medical schemes\u00a0are not paying for treatment for which they are legally obligated.<\/p>\n The CMS is now investigating whether Discovery and GEMS have failed to pay for Prescribed Minimum Benefits (PMBs) – with the\u00a0SAPPF claiming that the two schemes have found ways to circumvent paying the full amount.<\/p>\n Following the investigation announcement, the SAPFF asked its members for examples of claims that had not been paid in full or at all.<\/p>\n It reportedly\u00a0received more than\u00a021,000 lines of unpaid claims in one week (representing every medical aid), indicating that\u00a0that non-payment by medical aids was widespread, said SAPFF CEO Chris Archer.<\/p>\n Prescribed Minimum Benefits<\/strong><\/p>\n Medical aids are required by law to provide all their members with a minimum level of mandatory cover, called Prescribed Minimum Benefits.<\/p>\n Prescribed Minimum Benefits covers treatment for 26 of the most commonly occurring ailments and over 270 other conditions.<\/p>\n Medical aid providers will pay medical bills on behalf of a member. This might include paying for hospitalisation, medical procedures, doctor\u2019s consultations and certain medications.<\/p>\n