A PMB condition refers to a set of defined medical conditions for which payment for the treatment is guarenteed by Medical aids.

There are 270 stipulated conditions, medical emergencies and accidents INCLUDING 26 Chronic conditions. The classification of a PMB condition is based on the presenting symptoms and signs and not the aetiology of the condition. Bear in mind that Regulation 8 of the schemes act does make provision for payment to be guaranteed under certain requirements/provisions. These provisions have been put in place to ensure efficiency and effectiveness of healthcare provided and may not be used to deny members access to PMB benefits. It does however include requirements for pre Authorisation, application of treatment protocols, benefit definitions as well as the use of formularies. These managed care interventions are evidence based and in line with clinical best practise.

What can we as doctors do to assist patients with diagnosing and managing a PMB condition.

1. Use Correct ICD 10 Codes:

This is easy if you have diagnosed and coded PMB condition from the start.

But a PROBLEM arises if you are waiting for Lab results, X-rays or Specialist opinion before you confirm the condition as a PMB condition.

The PROBLEM is that you have now used a code that is a NON-PMB code while waiting for results and this non-PMB code has now been used on all claims.

For EXAMPLE:

You diagnose a patient with Irritable Bowel Syndrome(IBS) and use the ICD 10 code, K58.9 – a NON-PMB condition.

In the meantime the patient has been to an Emergency room because of continuous pain. Bloods where taken, X-Rays done and the patient discharged with IBS not classified as an Emergency.

Abdominal Ultrasound a few days later confirms acute cholecystitis – This changes the ICD 10code to K81.0 – a PMB condition.

PROBLEM:

  • First consult: ICD10 code: K58.9
  • X-Ray forms: ICD10 code: K58.9
  • Lab tests: ICD10 code: K58.9
  • Emergency visit to Casualties: K58.9
  • Medicine scripted for code K58.9

CONSEQUENCE:

Claims are all paid out of the patients savings account while the Medical Aid should now pay it out of the PMB benefit and NOT deplete the savings account.

WHAT TO DO?

Once the diagnosis has been confirmed as a PMB, the treating doctor can write a note/letter to confirm and motivate that the diagnosis and all treatment since the first visit was in fact for undiagnosed cholecystitis. The patient can now send this letter to all parties involved and ask for a resubmission of all claims using the correct ICD 10 code.

If the treatment of this patient requires follow up treatment and special investigations this condition will have to be registered with the Medical scheme for ongoing cover under the PMB benefits.

2. Familiarise yourself with correct Treatment protocol

Use the Chronic Disease List Formularies supplied when treating PMB conditions and always bear in mind the medical aid option your patient is on.

Familiarise yourself with specific Scheme protocols for PMB conditions. The patient also has a responsibility to bring with the necessary information on scheme rules and formularies to the consultations when dealing with their PMB condition.

If the standard treatment protocol is not suitable for your patient, a doctor can motivate for an alternative which should then be covered under the PMB benefit. It is therefore important that any adverse effects or treatment failure are documented showing that protocol has been tried and failed.

3. Are you a Designated Service provider(DSP)

If treated by a DSP for a PMB condition, full payment is guaranteed.

If treated by a non-DSP, a co-payment will be levied for the patients account.

All Emergencies, classified as a PMB will be reimbursed for in full. Regardless of the treating doctor being a DSP or non-DSP.

4. The condition that seems to be a PMB but isn’t

Example1: Basal Cell Carcinoma

Treatment: Excision.

Medical aid might only reimburse as a PMB benefit if the histology showed the cells removed to be of a particular depth.

Example 2: Hypertension

But when you treat a patient for mild Hypertension prescribing a dosage lower than the dosages prescribed by the treatment protocol, the medical aid can turn around and claim that it does not meet the criteria to qualify as a PMB.

5. Pre Authorisation:

Medical schemes can make a benefit conditional on you obtaining pre authorisation or joining a benefit management programme.

6. The Emergency that isn’t an Emergency:

Example: Patient had chest pains but ECG reports showed later it not to be a Miocardial infarct(MI).

Outcome:

In this case the Scheme was obliged to pay for the Emergency room visit, treatment and all medicines aimed at treating the presenting signs and symptoms of a suspected MI – a PMB condition. However once the ECG’s confirmed there was no MI the medical aid is no longer obliged to pay from PMB benefits for any special investigations that was done to prove the condition was not a PMB condition.

7. What if the Standard Treatment is not suitable:

The Medical Schemes act allows schemes to develop treatment plans for a PMB as long as the treatment is equal to or better than the minimum standards for each PMB condition as provided by law.

If the standard treatment protocol is not suitable for your patient, a doctor can motivate for an alternative which should then be covered under the PMB benefit. It is therefore important that any adverse effects or treatment failure are documented showing that protocol has been tried and failed.

The member faces another series of difficulties with the administrative battle caused by incorrect coding and the intermittent paperwork required to obtain payment by the scheme. It is particularly difficult when members are required to fill out reams of forms or are expected to re-submit forms annually for chronic conditions. Under these circumstances, it is sometimes difficult for the member to get busy practitioners to complete these forms and/or they are charged by the provider to complete them. This often leads to them rather giving up on the battle.

By being mindfull of PMB ICD 10 coding, diagnosis and treatment in line with scheme rules and the benefits available to the patient, you as the practioner can make the positive difference. If you are aware that your patients PMB condition are not being reimbursed from their PMB benefits, advise them to contact the Council for Medical Schemes and lodge a complaint.

For a copy of all PMB condition ICD 10 codes, Gazetted CDL treatment protocols or assistance with any of your PMB queries please contact Dr Niel Oets at Medprax on 031 9049200 or send an e-mail to Niel@mepdrax.co.za

By Dr Niel Oets, Chief Executive Officer, Medprax.

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