'Medical specialists overcharging in SA'

Research shows that some specialists are abusing the rules for PMBs by increasing fees.

Clamps, scissors and other surgical instruments are seen in an operating room. Picture: AFP.

CAPE TOWN - Christoff Raath, an actuary and CEO of the Health Monitor Company, on Tuesday revealed some medical specialists have been abusing the rules for prescribed minimum benefits (also known as PMBs) by increasing fees for treatments, knowing they are guaranteed payment.

Raath's research shows 40 percent of the largest anaesthetist practices in South Africa are charging explicitly for their services when surgery happens to be classified as a benefit.

Under the current rules, a medical scheme must pay in full for any treatment of the benefit irrespective of the fee charged.

As a result of this incentive, medical schemes are reluctant to pay out for the benefits, this results in increasing complaints from medical aid members.

Cape Talk 567's Kieno Kammies spoke to the Health Monitor Company CEO and asked him to 'unpack' his findings.

Raath said, "We are seeing evidence that some specialist practices seem to charge more when they see a patient has a PMB."

He said the issue lies in the Medical Schemes Act, which provides for it.

"The Act requires that these PMBs be paid by medical schemes in full, without limits and without co-payments at cost."

Raath said one of more ironic manifestations in South Africa is that the country has no set of guidelines or ethical or reference tariffs as to what medical specialists are supposed to charge.

"If you're a doctor, there's no guideline whatsoever as to what you're supposed to charge your medical scheme members."

He said while there's a vast shortage of medical specialists in the country and there is no doubt that it costs a lot of money to maintain specialist practices, the problems arise when there's unequivocal abusive behaviour.

"What we're seeing is perhaps something that could be deemed exploitative behaviour."