Medical scheme disputes and the CMS
What the Council for Medical Schemes does when a South African scheme will not pay a practice's account, what PMBs are, and how to track disputed claims.
By Achekam · · 5 min read · For Healthcare businesses in South Africa
A claim goes to the medical scheme and comes back rejected, or paid at a fraction of the account. The reason code is cryptic, the call centre suggests resubmitting, and the resubmission comes back the same way. Meanwhile the patient believes the scheme has paid, the account ages in the practice's books, and the receptionist is unsure whether to bill the patient, fight the scheme or write it off.
South African practices have a regulator to turn to in some of these situations: the Council for Medical Schemes (CMS). Knowing what it does, and what it does not do, helps a practice decide where to put its effort. This article explains the CMS's role, how its complaints rulings work, what Prescribed Minimum Benefits are, and how to keep disputed amounts visible in the books while a dispute runs. For a large or complex dispute, take advice from someone who handles scheme disputes regularly.
The CMS supervises medical schemes
The CMS is a statutory body established by the Medical Schemes Act 131 of 1998 to provide regulatory supervision of private health financing through medical schemes. It is not a scheme, a claims administrator or a collections agency. Its role is to supervise the schemes and the way they conduct their business.
That shapes what a practice can expect. The CMS will not process a claim or pay an account. What it can do is consider whether a scheme has acted within the rules, and that is the lever a practice may use when a scheme refuses something it should not.
Complaints and the Complaints Adjudication Unit
The CMS publishes summaries of rulings by its Complaints Adjudication Unit on complaints against regulated entities under section 47 of the Medical Schemes Act. Reading a few of those summaries before lodging anything is worthwhile: they show how complaints are framed, what evidence is weighed, and how similar disputes have been decided.
The CMS adds an important caveat: these rulings are for information only and do not serve as legal precedents. A ruling in favour of another practice on a similar claim is useful guidance, but it does not bind the CMS to decide your complaint the same way, and it does not oblige a scheme to pay you. Use rulings to understand the issues, not to predict your own result.
Before considering a complaint, a practice should already have:
- Submitted the claim correctly and on time.
- Received the scheme's rejection or short payment in writing.
- Queried it with the scheme and kept the reply.
- Confirmed with the patient what their benefit option covers.
The Council for Medical Schemes website explains the CMS's role, publishes the complaints rulings and sets out how complaints are lodged.
Prescribed Minimum Benefits
Many disputes turn on Prescribed Minimum Benefits (PMBs). The CMS describes PMBs as defined benefits that ensure certain minimum health services. Where a patient's condition and treatment fall within them, the question of whether a scheme should pay looks very different from a claim for a benefit the patient's option simply does not include.
A practice does not need to master the detail of PMBs to use them well. It needs to recognise when a rejected claim might involve one, record the diagnosis and treatment accurately on the claim, and ask the scheme specifically how it has treated the claim in light of PMBs. If the answer is unsatisfactory, that is the point at which to consider whether a CMS complaint is worth making.
Demarcation: when the cover is not a scheme
The CMS also has a demarcation function, which concerns entities whose insurance products are exempted from doing the business of a medical scheme. For a practice, the practical point is that not every product a patient calls "medical cover" is a medical scheme. If the patient's cover turns out to be an insurance product rather than a scheme, ask the insurer and the patient which rules and which regulator apply before deciding how to pursue the claim.
Tracking disputed amounts in the books
A disputed claim is still money the practice is owed until it is collected, billed to the patient or written off. On Achekam, receivables are aged into 0-30, 31-60, 61-90, 91-120 and over 120 days, with overdue totals. That age analysis is the place to watch disputes, because a dispute that drags on quietly moves a balance from current to seriously overdue.
A few habits help:
- Review disputed balances monthly, as a short list beside the age analysis, with the stage each dispute has reached.
- Keep the patient informed. The server produces a customer statement of account as a PDF that can be e-mailed, and the screen says whether it was sent. A patient who sees the balance, with a note that the practice is disputing the scheme's decision, is far less likely to be surprised later. How statements and reminders work is covered in statements and reminders for patient accounts.
- Decide when to move on. If the scheme's decision stands, the balance may fall to the patient, as discussed in collecting the balance after medical aid pays part.
Keeping the dispute file together
A complaint or a query is only as strong as its paperwork. Achekam's Document Centre is a folder-based store where a practice can keep one folder per disputed claim: the original claim, the scheme's rejection or remittance, every e-mail and letter exchanged, the clinical notes relevant to the coding, and any complaint lodged. Files can be tagged and searched, and when a revised claim or a new letter arrives, a new version keeps the earlier ones, so the history is complete.
Achekam does not submit claims to schemes or lodge complaints with the CMS. The practice does that; Achekam keeps the money owed and the evidence in order.
A monthly disputes review
Once a month, list every claim the practice is disputing, the scheme involved, the amount, how long it has been outstanding and the next step. Decide for each whether to query again, consider a complaint, bill the patient or write it off, and record the decision in the claim's folder.
General guidance only, not advice on your own circumstances. Tax and payroll rules change: check the current position with the authority or your adviser.
