The importance of ICD-10 codes
One of the types of codes that appear on healthcare provider accounts is known as ICD-10 codes. These codes are used to inform medical schemes about what conditions their members were treated for so that claims can be settled correctly.
ICD-10 stands for International Classification of Diseases and Related Health Problems (10th revision). It is a coding system developed by the World Health Organisation (WHO), that translates the written description of medical and health information into standard codes, e.g. J03.9 is an ICD-10 code for acute tonsillitis (unspecified) and G40.9 denotes epilepsy (unspecified).
When you join a medical scheme, you choose and pay for a particular benefit option. This benefit option contains a basket of services that often has limits on the health services that will be paid for. Because ICD-10 codes provide accurate information on the condition you have been diagnosed with, these codes help the medical scheme to determine what benefits you are entitled to and how these benefits could be paid.
This becomes very important if you have a PMB condition, as these can only be identified by the correct ICD-10 codes. Therefore, if the incorrect ICD-10 codes are provided, your PMB-related services might be paid from the wrong benefit (such as from your medical savings account), or it might not be paid at all if your day-to-day or hospital benefits limits have been exhausted.
ICD-10 codes must also be provided on medicine prescriptions and referral notes to other healthcare providers (e.g. pathologists and radiologists) who are not all able to make a diagnosis. Therefore, they require the diagnosis information from your referring doctor so that their claim to your medical scheme can also be paid out of the correct pool of money.
Important note: Medical schemes are obliged by law to treat information about members' conditions with the utmost confidentiality. They are not allowed to disclose even ICD-10 codes to any other party, including employers or family members.
Responsibilities regarding PMB's
Medical scheme beneficiaries
PMBs are very good news for medical scheme beneficiaries and give them considerable rights as far as healthcare is concerned. However, as a consumer you also have certain responsibilities to ensure that PMBs work as well for you as they should.
- First and foremost, educate yourself about your medical scheme's rules, the listed medication and treatments (formularies) for your specific condition, as well as who the Designated Service Providers (DSPs) are.
- Obtain as much information as possible about your condition and the medication and treatments for it. If there is a generic drug available, do your own research to find out whether there are any differences between it and the branded drug.
- Don't bypass the system: if you must use a GP to refer you to a specialist, then do so. Make use of your medical scheme's DSPs as far as possible. Stick with your scheme's listed drug for your medication unless it is proven to be ineffective.
- Be a good consumer: ask questions and follow the complaints process if you are not treated fairly.
- Make sure your doctor submits a complete account to the medical scheme. It is especially important that the correct ICD-10 code is reflected.
- Follow up and check that your account is submitted within four months and paid within 30 days after the claim was received (accounts older than four months are not paid by medical schemes).
Among other objectives, PMBs want to achieve appropriate healthcare, resulting in lower costs associated with complications and hospitalisation. When beneficiaries are properly taken care of and their illnesses managed, the need for expensive hospitalisation decreases.
Medical schemes have a critical role to play in making PMBs work.
- Schemes have to educate their beneficiaries about PMBs and the benefits that are included in them.
- Schemes must inform their beneficiaries of their DSPs and keep them updated should any changes occur.
- Schemes should empower their beneficiaries with information on matters such as the intricacies of rules and the formularies for specific conditions.
- Medical schemes have to guarantee and ensure reasonable access and availability of DSPs.
- The public sector cannot be designated as a DSP without the medical scheme ensuring that the necessary service will be available.
Doctors do not usually have a direct contractual relationship with medical schemes. They merely submit their accounts and if the medical scheme does not pay, for whatever reason, the doctor turns to the beneficiary for the amount due. This does not mean that PMBs are not important to healthcare providers nor that they don't have a role to play in its successful functioning.
- Doctors should familiarise themselves with ICD-10 codes and how they correspond with PMB codes. If you use the correct ICD-10 code your account will definitely be paid as PMBs enjoy guaranteed medical aid cover.
- Consider on which option your patients are and what can realistically be covered before recommending a drug or treatment.
- Alert patients to the fact that their condition is a PMB and encourage them to engage their medical scheme on the matter.
- Keep proper clinical records of patients so that when a formulary drug or protocol is not effective, or causes adverse side-effects, you can justify your alternative recommendation.
- Do not abuse PMBs. The result will be an unsustainable private healthcare system with unaffordable contribution increases. Abuse could compel government to consider alternative payment options in the private healthcare sector.
- Allow your practice to be listed as a DSP.
- The "payment in full" concept is there to ensure accessibility of healthcare services for medical scheme beneficiaries if the DSP is not available; it is not a reimbursement model.
When do co-payments apply to PMBs?
Co-payments can only be levied when members voluntarily choose not to go to a DSP for a specific service, and/or when beneficiaries voluntarily decide not to use protocol or formulary medication or treatments.
Co-payments have to be specified in the medical scheme rules and may never be 100% of the cost of the service or medication. Schemes are also not allowed to recover co-payments from beneficiaries' savings accounts.
Medical scheme beneficiaries
Is my medical scheme obliged by law to provide cover for certain medical conditions?
Yes, these are known as Prescribed Minimum Benefits (PMBs). They were introduced into the Medical Schemes Act to ensure that beneficiaries of medical schemes would not run out of benefits for certain conditions and find themselves forced to go to State hospitals for treatment. These PMBs cover a wide range of ±271 conditions, such as meningitis, various cancers, menopausal management, cardiac treatment and many others, including medical emergencies. However, take note that certain limitations could apply, such as the use of a Designated Service Provider and specified treatment standards.
PMB diagnosis, treatment and care are not limited to hospitals. Treatment can be received wherever it is most appropriate, including a clinic, outpatient setting or even at home. Always check your benefits with your medical scheme and make sure you have the scheme's rules at your disposal.
Is it true that schemes now also have to provide chronic medication?
Yes, the list of PMBs includes 26 common chronic diseases in the Chronic Disease List (CDL) and other chronic conditions within the ±271 Diagnosis Treatment Pair (DTP) section. Medical schemes have to provide cover for the diagnosis, treatment and care of these diseases. However, you should remember that a medical scheme does not have to pay for diagnostic tests that establish that you are not suffering from a PMB condition.
The treatment algorithms (guidelines for appropriate treatment) for each of the CDL chronic conditions have been published in the Government Gazette while the chronic diseases in the DTP section are guided by the public sector protocols. This assures you of good quality treatment and reassures your medical scheme that it will not have to pay for unnecessary treatment. Your doctor should know and understand most of the guidelines so that he or she can help you get the treatment you need for any of these conditions without incurring costs that your scheme does not cover.
Why are some chronic illnesses covered and some not?
The diseases that have been chosen are the most common, they are life-threatening, and are those for which cost-effective treatment would sustain and improve the quality of the member's life.
Does my scheme need to do anything to ensure that the Designated Service Provider can treat me?
The Council for Medical Schemes has been advising medical schemes to enter into contracts with any DSP they choose, especially State hospitals, to ensure that these providers can supply the necessary services. Many State hospitals have set up separate wards to serve beneficiaries whose treatment and hospital stay is paid for by their medical scheme and to whom the hospital can then afford to provide better service. Other schemes have made arrangements with private hospital and certain retail pharmacies to treat their beneficiaries.
Can I be refused cover for the chronic conditions if I do not get authorisation or have certain tests?
Yes, medical schemes can make a benefit conditional on you obtaining pre-authorisation or joining a benefit management programme. These programmes are aimed at educating members about the nature of their disease and equipping them to manage it in a way that keeps them as healthy as possible. For example, many schemes offer treatment through groups that manage diseases such as diabetes, and are equipped to give the medication and monitor that disease.
Can my scheme insist that it will only fund treatment that follows the appropriate protocol?
Yes. The minimum medicines for treatment of all PMB conditions have been published in the Government Gazette, and are known as treatment algorithms (benchmarks for treatment). Your scheme may decide for which medicines it will pay for each chronic condition, but the treatment may not be below the standards published in the treatment protocols. If your scheme's cover conforms to that standard and you and your doctor decide that you should rather use different medication, then you may have to pay a co-payment towards the cost of that medicine. Your medical scheme must, however, pay for the treatment if your doctor can prove that the standard medication is ineffective or detrimental to your condition.
Your medical scheme may develop protocols to manage the use of benefits. Such protocols would specify, for example, types of tests, investigations and number of consultations. Members who might need more frequent or extra services than provided for in the protocols, can appeal to their scheme for these to be covered. The scheme's appeal process might include a motivation from the treating doctor that explains the clinical reasons for the additional services
Can my scheme refuse to cover my medication if I need, or want, a brand other than that which the scheme says it will pay for?
Yes, the medical scheme may refuse to cover a part of the expenses. Your scheme may draw up what is known as a formulary – a list of safe and effective medicines that can be prescribed to treat certain conditions. The scheme may state in its rules that it will only cover your medication in full if your doctor prescribes a drug on that formulary. Generally speaking, schemes expect their members to stick to the formulary medication.
Often the medicines on the list will be generics – copies of the original brandname drug – that are less expensive but equally effective. If you want to use a brandname medicine that is not on the list, your medical scheme may foot only part of the bill and you will have to pay either the difference between the price of the medication you use and the one on the formulary, or a percentage co-payment as registered in the scheme rules.
If you suffer from specific side-effects from drugs on the formulary, or if substituting a drug on the formulary with one you are currently taking affects your health detrimentally, you can put your case to your medical scheme and ask the scheme to pay for your medicine. You can also appeal to the scheme if the formulary drug is ineffective and does not have the desired effect. If your treating doctor can provide the necessary proof and the scheme agrees that you suffer from side-effects, or that the drug is ineffective, then the scheme must give you an alternative and pay for it in full.
Can my scheme make me pay for a PMB from my savings account?
No, the regulations state that schemes cannot use your medical savings account to pay for PMBs.
Can my scheme make me pay a co-payment or levy on a PMB?
No, your scheme cannot charge you a co-payment or levy on a PMB if you follow the scheme formulary and protocol. However, if your scheme appoints a Designated Service Provider (DSP) and you voluntarily use a different provider, your scheme may charge you the difference between the actual cost and what it would have paid if you had used the DSP or the percentage co-payment as registered in the scheme rules.
Can schemes still set a chronic medicine limit?
Yes, your scheme can set a limit for your chronic medicine benefit. Any chronic medication you claim for will then reduce that limit, regardless of whether or not it is one of the PMB chronic conditions. However, if you exhaust your chronic medicine limit, your scheme will have to continue paying for any chronic medication you obtain from its DSP for a PMB condition.
Can medical schemes prescribe protocols and formularies?
Schemes can most certainly prescribe treatment protocols in terms of PMBs to improve their risk management. However, should medical schemes make use of formularies, these must be developed on the basis of evidence-based medicine, taking cost-effectiveness and affordability into account while also being on par with the gazetted algorithms for chronic diseases and the public sector protocols for the Diagnosis Treatment Pairs.
Is there a process to follow when the formulary is not effective for a specific patient?
An appeals process is in place for a medical scheme member to request his or her scheme to carry the costs for treatment outside the scheme's formulary. It is very important that complete medical records are submitted in support of the request. As the treating doctor, it is your responsibility to record the patient's reaction to the formulary treatment, including all efforts that were made to determine correct dosages and/or other possible contributing factors.
If the PMB codes do not always correspond with the ICD-10 codes, what do I do to ensure a correct account?
The Council for Medical Schemes has compiled a guideline on how to reconcile the two sets of codes. However, whenever there are differences between the ICD-10 codes and PMB codes, the latter takes precedence. This guideline is available on the CMS website www.medicalschemes.com under the Regulatory Info menu as "Prescribed minimum benefit ICD-10 coding".