Prescribed Minimum Benefits complaints: a five-year retrospective review
Background: No matter which benefit option members have chosen, medical schemes are required by the Medical Schemes Act no. 131 of 1998 to pay costs associated with the diagnosis, treatment, or care of a specified set of benefits known as Prescribed Minimum Benefits (PMBs). Medical scheme beneficia...
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| Language: | English |
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South African Medical Association
2024-06-01
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| Series: | South African Medical Journal |
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| Online Access: | https://samajournals.co.za/index.php/samj/article/view/1007 |
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| author | Lindelwa Mitchele Ngobeni Lucky Moropeng Evelyn Thsehla |
| author_facet | Lindelwa Mitchele Ngobeni Lucky Moropeng Evelyn Thsehla |
| author_sort | Lindelwa Mitchele Ngobeni |
| collection | DOAJ |
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Background: No matter which benefit option members have chosen, medical schemes are required by the Medical Schemes Act no. 131 of 1998 to pay costs associated with the diagnosis, treatment, or care of a specified set of benefits known as Prescribed Minimum Benefits (PMBs). Medical scheme beneficiaries have the right to lodge complaints with the Council for Medical Schemes (CMS) when their claims are denied.
Objective: To determine and describe the pattern of PMBs complaints received by CMS from January 2014 to December 2018.
Methods: This was a cross-sectional study that utilised the CMS’ clinical complaints. Data for PMBs, complainants, medical scheme types, and reasons for payment denial were extracted. The CMS’ lists of chronic conditions, PMBs, and registered schemes were used to confirm PMBs and to categorise schemes as either restricted (i.e., to only members of specific organisations) or open (i.e., to all South Africans). Extracted and coded data were analysed using SAS v.9.4 software.
Results: A total of 2141 complaints were retrieved and 1124 PMBs complaints were included in the study. The median of PMBs complaints per year was 225. Most of the complaints (43.6%, n=490/1124) were lodged by members themselves. Non-Communicable Diseases (NCDs) constituted most of the PMBs conditions that members complained about. Medicine and surgery were the services that were mostly denied full payment by medical schemes. Open medical schemes accounted for more (73.8%, n=830/1124) of the complaints.
Conclusion: Chronic conditions are the main diseases that medical scheme members complained about. Member education and clear definition of PMBs should be prioritised by medical schemes and the Council for Medical Schemes.
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| format | Article |
| id | doaj-art-8f8d732455cf4f319a0f2151b3d756e3 |
| institution | Kabale University |
| issn | 0256-9574 2078-5135 |
| language | English |
| publishDate | 2024-06-01 |
| publisher | South African Medical Association |
| record_format | Article |
| series | South African Medical Journal |
| spelling | doaj-art-8f8d732455cf4f319a0f2151b3d756e32025-02-10T12:25:58ZengSouth African Medical AssociationSouth African Medical Journal0256-95742078-51352024-06-011146b10.7196/SAMJ.2024.v114i16b.1007Prescribed Minimum Benefits complaints: a five-year retrospective review Lindelwa Mitchele Ngobeni0https://orcid.org/0009-0003-1187-7182Lucky Moropeng1https://orcid.org/0000-0003-3789-5664Evelyn Thsehla2https://orcid.org/0000-0003-4098-5804Schools of Health Systems and Public Health, Faculty of Health Sciences, University of PretoriaSchools of Health Systems and Public Health, Faculty of Health Sciences, University of Pretoria2SAMRC/WITS Centre for Health Economics and Decision Science, Wits School of Public Health, Faculty of Health Sciences Background: No matter which benefit option members have chosen, medical schemes are required by the Medical Schemes Act no. 131 of 1998 to pay costs associated with the diagnosis, treatment, or care of a specified set of benefits known as Prescribed Minimum Benefits (PMBs). Medical scheme beneficiaries have the right to lodge complaints with the Council for Medical Schemes (CMS) when their claims are denied. Objective: To determine and describe the pattern of PMBs complaints received by CMS from January 2014 to December 2018. Methods: This was a cross-sectional study that utilised the CMS’ clinical complaints. Data for PMBs, complainants, medical scheme types, and reasons for payment denial were extracted. The CMS’ lists of chronic conditions, PMBs, and registered schemes were used to confirm PMBs and to categorise schemes as either restricted (i.e., to only members of specific organisations) or open (i.e., to all South Africans). Extracted and coded data were analysed using SAS v.9.4 software. Results: A total of 2141 complaints were retrieved and 1124 PMBs complaints were included in the study. The median of PMBs complaints per year was 225. Most of the complaints (43.6%, n=490/1124) were lodged by members themselves. Non-Communicable Diseases (NCDs) constituted most of the PMBs conditions that members complained about. Medicine and surgery were the services that were mostly denied full payment by medical schemes. Open medical schemes accounted for more (73.8%, n=830/1124) of the complaints. Conclusion: Chronic conditions are the main diseases that medical scheme members complained about. Member education and clear definition of PMBs should be prioritised by medical schemes and the Council for Medical Schemes. https://samajournals.co.za/index.php/samj/article/view/1007Medical SchemesPrescribed Minimum BenefitsComplaints |
| spellingShingle | Lindelwa Mitchele Ngobeni Lucky Moropeng Evelyn Thsehla Prescribed Minimum Benefits complaints: a five-year retrospective review South African Medical Journal Medical Schemes Prescribed Minimum Benefits Complaints |
| title | Prescribed Minimum Benefits complaints: a five-year retrospective review |
| title_full | Prescribed Minimum Benefits complaints: a five-year retrospective review |
| title_fullStr | Prescribed Minimum Benefits complaints: a five-year retrospective review |
| title_full_unstemmed | Prescribed Minimum Benefits complaints: a five-year retrospective review |
| title_short | Prescribed Minimum Benefits complaints: a five-year retrospective review |
| title_sort | prescribed minimum benefits complaints a five year retrospective review |
| topic | Medical Schemes Prescribed Minimum Benefits Complaints |
| url | https://samajournals.co.za/index.php/samj/article/view/1007 |
| work_keys_str_mv | AT lindelwamitchelengobeni prescribedminimumbenefitscomplaintsafiveyearretrospectivereview AT luckymoropeng prescribedminimumbenefitscomplaintsafiveyearretrospectivereview AT evelynthsehla prescribedminimumbenefitscomplaintsafiveyearretrospectivereview |