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When a patient is referred to a pathologist or radiologist by their doctor for specific tests needed to correctly diagnose or determine how severe a specific condition is and the condition is a Prescribed Minimum Benefit (PMB), an emergency or on the list of chronic conditions, the cost should be covered from the risk pool (pool of funds) and not from the member’s savings, or if there are no savings, rejected.
Medical scheme claims are assessed according to ICD10 codes, a process which happens routinely without human intervention. If the ICD10 code does not indicate a PMB, emergency or chronic condition, the claim would be paid from the savings account or not at all. As no diagnosis has yet been made by the doctor, a PMB ICD10 code cannot be noted on the form by the doctor requesting the tests.
However, once the tests are done, the pathologist can only write a report, not diagnose the condition. Only the treating doctor can do that. The lab therefore sends a report to the doctor; but it submits the account for the tests directly to the medical scheme, with a generic or “Z” ICD10 code.
The Medical Scheme’s system does not recognise the ICD10 code as referring to a PMB, emergency or chronic condition and therefore doesn’t pay for it from the risk pool.
Most members don’t even notice that these accounts are being paid from their medical savings accounts which might be one of the reasons why some savings accounts are used up early in the year.
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