BHF’s decision not to issue of practice numbers for RWOPS

The Board of Healthcare Funders (BHF) has stopped allocating PCNS numbers to medical practitioners doing RWOPS (Remunerative Work outside the Public Service), allegedly, at the bidding of the Department of Health. This development has led to SAMA being approached with many queries from disgruntled members who have permission to do RWOPS but are unable to obtain practice numbers.

What follows is aimed at addressing this prejudice and to offer possible solutions to the current impasse:

About RWOPS

The granting of permission to do RWOPS is not only applicable to medical practitioners - it applies to all public servants and is in terms of the provisions of Section 30 of the Public Service Act.

According to Section 30 of the Public Service Act, “… (1) No employee shall perform or engage himself or herself to perform remunerative work outside his or her employment in the relevant department, except with the written permission of the executive authority of the department.” Furthermore,” If the executive authority fails to make a decision within the 30 day period, it would be deemed that such permission was given.”

Permission, once granted, should be all systems go for the medical practitioner. The Public Service Act does not contemplate further hindrances and or obstacles. After all, the provisions of the Act should be equally applicable to all public servants and this should be without discrimination or preferential treatment.

The latest position taken by BHF and the Department of Health, is not in keeping with the provisions of the Public Service Act and is fraught with prejudicial discrimination given that those already practicing RWOPS have allocated Practice Numbers?

PCNS, BHF, CMS and DOH relationship

PCNS stands for Practice Code Numbering System. Regulation 1 of the Medical Schemes Act no 131 of 1998 defines it as, “the number allotted to a supplier of a relevant health service as a practice number by an organisation or body approved by the Council for Medical Schemes (CMS)”.  It is in terms of this very provision that CMS has tasked BHF with the responsibility of allotting practice numbers to suppliers of health service.

However, given that CMS is established in terms of Section 3 of the Medical Schemes Act, and is answerable to the Minister of Health, it is therefore fitting that BHF is working on the instruction of CMS; possibly in response to a directive that has been issued by the Department of Health.

It is our firm believe that the decision to declare a moratorium on the issuing of practice numbers to newly approved RWOPS medical practitioners did not follow due process, is procedurally unfair, discriminates against medical practitioners, is unreasonable and contravenes the Promotion of Administrative Justice Act ( PAJA). Therefore, there is a compelling case for this unfair and unilateral decision to be challenged and to ensure that it is reversed.

GEMS vs Dr N Burman, Case Law

In the case that came before the Appeal Committee, the Government Employees' Medical Scheme (GEMS) refused to refund a member for services rendered by a specialist physician, Dr N Burman, who runs a cash practice and does not have a BHF practice code number. The member paid Dr Burman from his own pocket and then sub-mitted the claim to GEMS, which rejected the claim because of the absence of the practice code. Dr Burman is registered with the Health Professions Council of South Africa (HPCSA) as a medical practitioner. In June, the Registrar of Medical Schemes, Dr Monwabisi Gantsho, directed GEMS to refund the member. GEMS appealed against the registrar's ruling.

The Appeal Committee considered the Medical Schemes Act, which states that schemes must pay valid claims within 30 days of receiving them and a regulation under the Act that details what should be on an account submitted as a claim. The regulation says the account must include "the practice code number; group practice number and individual provider registration number issued by the registering authority tor providers, if applicable, of the supplier of service and in the case of a group practice, the name of the practitioner who provided the service". The Appeal Committee, chaired by Ngwako Hamilton Maenetje SC, says this means that the practice code number is required only if it is applicable, and there was no reason for GEMS not to pay the claim. Source: BHF Website

This is a CMS Appeals Committee ruling, in terms of which a practice number is not required in order for practitioners to consult medical aid patients. This is as long as the practitioners charge cash and do not claim directly from the medical aid. The ruling obliges medical schemes to compensate patients who submit proofs of payments of claims that do not display a practice number.

What affected practitioners should know?

 

1. Permission to do RWOPS, once granted, allows them to do remunerative work outside public service.
2. They can consult private patients, charge them cash, and issue them with proof of settlement of the account. The patient then has to recover their payment from the medical aid.
3. In terms of the aforementioned ruling, the medical scheme will be obliged to compensate the claimant provided the claimant is a member in good standing of the medical aid in question.
4. Although medical practitioners need a practice number if they want to claim directly from the medical aid scheme, nothing stops them from consulting patients and charging cash for their services.
5. The position stands, until reversed by a competent court or by the Appeals Board of the Council For Medical Schemes

In Conclusion

The need to root out unfair practices that are being meted out at practitioners cannot be overemphasised. The impunity with which these decisions are being made is a cause for concern. Practitioners need to take a firm stand against these unilateral draconian decisions.