During a webinar sponsored by the Southern African Spinal Cord Association (SASCA) and the QuadPara Association of South Africa (QASA) on health law, Elsabé Klinck, from Elsabé Klinck and Associates, spoke about how medical staff can better support patients with accessing the necessary funding to afford the best possible care.
“Patients are often unaware of what is considered prescribed minimum benefits (PMB),” Klinck said during the webinar. “And, we have come to accept it when medical aids refuse to cover costs. Healthcare workers need to tell the patient when a medical service is a PMB and needs to be covered in full.”
Medical aids are by law required to carry the costs of PMBs with no co-payment for the patient. While medical aids can limit the rights of patients, outlining the extent to which PMBs are covered, this needs to be a transparent process with adequate reasoning.
“If we want to limit rights, we need to be transparent and make clear what the basis is,” Klinck explained. She added that there are also exceptions when care might exceed PMBs, but still need to be covered by the medical aid, for example, if the standard treatment isn’t effective on the client, or if the standard care could potentially cause harm.
Klinck urged medical staff and patients to challenge the medical aids on their decisions to fund or not fund care if the treatment isn’t deemed adequate or covered in full. While medical staff might be cautious of damaging their relationship with the medical aids, Klinck referred to legislation that protects healthcare workers against discrimination.
“The medical aid can’t discriminate against healthcare workers if they support the patient in getting funding,” she said. She quotes the Medical Schemes Act, Chapter 5, regulation 15 E:
“A participating healthcare provider may not be forbidden in any manner from informing patients of the care they require, including various treatment options, and whether, in the health care provider’s view, such care is consistent with medical necessity and medical appropriateness.”
Nor can any agreement between healthcare workers and medical aids be ended if the staff support the patient in securing funding.
However, if medical staff are still reluctant to assist, the least they can do is provide patients with knowledge and education on when they should pursue better funding.
In Rolling Inspiration Issue 5 2021, we will take a closer look at when to approach your medical aid, the best way to challenge funders and ways in which medical staff can support patients.