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| Healthcare
providers |
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| Can medical schemes prescribe protocols
and formularies? |
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| 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. |
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| Is there a process to follow when the
formulary is not effective for a specific patient? |
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| 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. |
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| If the PMB codes do not always correspond
with the ICD-10 codes, what do I do to ensure a correct account? |
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| 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”. |
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