Medical aid: CMS told to consolidate case against SAMA

The Council for Medical Scheme (CMS) has been ordered by the Competition Tribunal to submit further particulars and consolidate its case against the South African Medical Council (SAMA).

In 2013, the CMS filed a complaint with the Competition Commission alleging that in 2009, medical tariffs determined by SAMA allowed paediatricians to bill an extra 50% above the medical aid rate payable for new born babies requiring intensive care.

The CMS lodged a second complaint that same year regarding the 2010 billing guidelines of the Society for Cardiothoracic Surgeons of South Africa (SOCTSA).

According to the Tribunal, the CMS alleged that for both cases the application of these tariffs were prohibited under the Competition Act.

The latest decision

The Tribunal has now given the CMS 20 business days to consolidate its pleadings with regards to both complaints it lodged in 2013 against SAMA and two other organisations for price fixing. At the same time, the Tribunal has dismissed SAMA’s application to have the complaints dismissed. In a statement the Tribunal clarified that the CMS is required to provide the particularity sought by SAMA in relation to its complaint against SAMA.

Furthermore, the Tribunal has tasked the CMS with elaborating “on the recommendation and the binding nature of SAMA’s publication, and why it’s important for SAMA to publish these guidelines and how SAMA is able to achieve compliance with these guidelines by the paediatricians/ neonatologists. CMS needs to outline what mechanisms, if any, are utilised by SAMA to punish non-compliance. And that the CMS must amend its complaint limiting it only to the complaint by Dr Botha, a cardiothoracic surgeon who performed a coronary artery bypass surgery on a patient who was a member of PROFMED Medical Scheme.”

In explaining its decision, the Tribunal said: “The (2013) referrals have obviously evolved overtime and such evolution has given rise to confusions and contradictions between all the various affidavits CMS has filed.”

As the case is still in progress, the CMS was unable to offer commentary.

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