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Healthcare providers
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.