Decoding Medical Aid Speak

The terminology used by medical aid schemes is both bewildering and esoteric, leaving one surmising why English is a scholarly prerequisite. You contact your medical scheme in search of an answer to a query relating to a recent medical bill and are confronted by an ever so helpful medical aid consultant on the other end of the telephone line, happily using jargon such ICD10 code, PMB, DSP, exclusion, formulary, savings account, threshold limit, emergency condition and so forth. What do all these terms mean and how can it help you, the member, to know what they mean?

Understanding what these terms mean can make the difference between having an account paid - or not! As an example, I recently had several doctors’ bills rejected by my own medical aid scheme because of incorrect ICD -10 coding. Now, if I were not a veteran of “Geek Speak”, I might have given up and assumed that these procedures were simply “not being covered by the scheme”. ICD-10 stands for International Classification of Diseases and Related Health Problems (10th revision) and is a coding system developed by the World Health Organisation that translates the written description of medical and health information into standard codes, e.g. JO3.9 is an ICD-10 code for acute tonsillitis (unspecified).

When you join a medical scheme, you choose and pay for a specific benefit option that contains a basket of services that often has limits on the health services that will be paid for. Because ICD-10 codes provide accurate information on the condition you have been diagnosed with, these codes assist the medical scheme to determine what benefits you are entitled to and how these benefits could be paid.If you have a PMB condition, this becomes extremely important, as these can only be identified by the correct ICD-10 codes. Therefore, if the incorrect ICD-10 codes are provided, your PMB related services might be paid from the wrong benefit (such as your medical savings account), or it might not be paid at all if your day-to-day or hospital benefits limits have been exhausted. Hence, the solution to my particular problem was to contact my doctor and obtain the correct coding. Administration errors occur all the time! Don’t fall prey to them.

So what exactly is that “animal” called a PMB? Prescribed Minimum Benefits (PMB) is a set of defined benefits to ensure that all medical scheme members have access to certain minimum health services, regardless of the benefit option that they selected and were introduced into the Medical Schemes Act to ensure that beneficiaries of medical schemes would not run out of benefits for certain conditions and find themselves forced to go to State hospitals for treatment.

PMBs cover a wide range of ± 270 conditions, including medical emergencies and 26 chronic conditions as defined in the Chronic Disease List. An emergency medical condition means the sudden and, at the time, unexpected onset of a health condition that requires immediate medical treatment and/or operation. For example, cosmetic surgery would not normally be covered by a medical scheme. However, you find yourself having such surgery and as a result incur septicemia. Septicemia is a PMB condition and therefore the related treatment has to be paid for out of PMB benefits.

Two common questions relating to PMBs are; “Can my scheme make me pay for a PMB from my savings account and can my scheme make me pay a co-payment or levy on a PMB?” No to the first and no to the second providing you follow the scheme formulary and protocol. Another question often asked is ‘Can schemes set a chronic medicine limit?” The answer is yes. Any chronic medication you claim for will reduce that limit, regardless of whether or not it is one of the PMB chronic conditions. However, if you exhaust your chronic medicine limit, your scheme will have to continue paying for any chronic medication you obtain from its DSP or Designated Service Provider. (Suppliers of drugs and services etc chosen for you by the medical scheme).

The list of terms used in the medical aid industry is pretty exhaustive, making it extremely difficult to cover each one in the limited space given to an editorial. However, a comprehensive list of explanations may be found at is the website for the Medical Schemes Council of SA.