CMS NEWSIssue 2 December 2016

Adjudication of member complaints by the CMS

PMBs review expected to clear grey areas and reduce

complaints

From Complaints to Compliments with

Momentum Health

Dr Humphrey Zokufa takes over reins at the CMS

for Medical SchemesCouncil The Member complaints handling issue

1

The Accredited Skills ProgrammeIs aimed at trustees and principal officers. Training is spread over two sessions of two days each. The programme is made up of unit standards which are quality assured by the Insurance Seta (INSETA), and registered on the National Qualifications Framework (NQF) carrying 30 South African Qualifications Authority (SAQA) credits. The Accredited Skills Programme upon completion, awards 24 Knowledge CPD points and 2 Ethics CPD points.

Trustee Induction TrainingIs a two day training session aimed mainly at newly appointed board of trustees. Participation in the training is open to all schemes. Participants consists of a mix of trustees from open and restricted schemes. This training programme is a pre-requisite for registering for the accredited skills programme.

The CMS also provides an Introductory Broker Training Programme. The Programme bears CPD points which are approved by the Financial Planning Institute. The CMS as an approved CPD provider, will introduce advanced Broker Training Programmes in 2017.

Prescribed Minimum Benefits Training is a scheme specific training programme offered to schemes upon request.

Details regarding the training dates are published on the CMS website: www.medicalschemes.com

Reading our newsletters is good for your health

Visit www.medicalschemes.com to access all our publications.

CMS Education & Training

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Editorial CommitteeDr Elsabé ConradieDr Anton de Villiers

Paresh PremaDr Sipho Kabane

Nondumiso KhumaloHannelie Cornelius

Pulane MolefeSilindubuhle Mnqeta

EditorPulane Molefe

ContributorsDr Elsabé Conradie

Dr Sipho KabaneThebekile Phaswane

Khayalethu MvuloToni van den Bergh

Alicia SchoemanCarl Grillenberger

Silindubuhle Mnqeta

CMS AddressBlock A

Eco Glades 2 Office Park420 Witch-Hazel Avenue

Eco ParkCenturion

0157

Contents

Copyright

CMS News is published by the Council for Medical Schemes (CMS). All material is copyrighted and cannot be used without the written permission from the publisher. The views expressed by external stakeholders do not necessarily reflect the views of the CMS. All material is correct at the time of going to print.

Editorial 2

Dr Humphrey Zokufa takes over reins at the CMS 3

Adjudication of member complaints by the CMS 5

Complaints and disputes appeal process 8

PMBs review expected to clear grey areas and reduce complaints

9

From Complaints to Compliments with Momentum Health 11

Alternative Dispute Resolution for complaints and disputes 12

Promoting patient education on utilisation of day hospitals as a cost-effective alternative for services

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Prescribed minimum benefits 16

for Medical SchemesCouncil

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Complaints and dispute management is an essential element to maintain good customer relations. It is no secret that the manner in which complaints and disputes are handled, has potential to make or break reputations of the entities concerned. Different sectors have principles and protocols in place which must be adhered to, when dealing with stakeholder complaints and disputes. The Medical Schemes Act, 131 of 1998 (the Act) makes provision for dealing with complaints and disputes involving medical schemes and members to ensure appropriate and speedy resolution of such matters. In this edition we focus on how the Council for Medical Schemes (CMS) deals with complaints and disputes received from medical scheme members, as part of exercising its regulatory oversight role in protecting members’ interests.

Chapter 10 of the Act outlines the procedure to be followed in handling complaints and disputes received by the CMS in relation to matters provided for in the Act. Each medical scheme is expected to have proper systems in place to deal with members’ complaints and disputes.

A report by the Centre for Utility Consumer Law at the University of Leicester in the United Kingdom Complaints handling: Principles and Best Practices, identifies some key principles that should form the basis of complaint handling systems for organisations, which include: Highly visible procedures; Easy and free access; effective company protocols for quality assurance; Fairness and consistency; Responsiveness; and Organisational ownership and commitment. The report also identifies service failure as a financial and reputational risk for entities. Complaints data on the other hand, is identified as a valuable source of information to assess systemic problems. The report’s message is clear – entities ignore stakeholder complaints at their own peril.

On 1 November the CMS welcomed on board Dr Humphrey Zokufa to take over the reins as Chief Executive and Registrar. CMS News had an opportunity to solicit comments from the new Registrar on his vision for the CMS, including the role that he envisages the regulator body to play in view of the impending NHI.

The articles Adjudication of member complaints by the CMS, and Complaints and disputes appeal process explain the process of how member complaints and disputes received by the CMS are handled. In the article PMBs review expected to clear grey areas and reduce complaints,

readers are given an insight on the current PMBs review process, an initiative that is expected to assists to clear any existing uncertainties in the interpretation and implementation of PMBs by all key stakeholders, and at the same time ensure alignment with the country’s healthcare policy direction.

From Complaints to compliments with Momentum is a story about how Momentum has successfully put systems in place to enhance staff competence in handling member complaints. Alternative Dispute Resolution (ADR) is a well-established platform for parties engaged in a dispute to engage in a neutral evaluation, and negotiated settlement of matters before they go to court. The CMS has successfully adopted ADR to deal with some of the disputes referred to the Council. The article Alternative Dispute Resolution for complaints and disputes outlines the process involved.

One of the concerns expressed by the panel during the Competition Commission’s Health Market Inquiry (HMI), related to the lack of information to patients regarding the utilisation of Day Hospitals as a cost-effective alternative for services. The Day Hospital Association of South Africa (DHASA) has now taken on the responsibility to promote patient education on the utilisation of day hospitals as an alternative for surgical procedures. We take a closer look at the issue in this edition.

Editorial

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Dr Humphrey Zokufa takes over reins at the CMS

On 1 November 2016 the Council for Medical Schemes (CMS) welcomed Dr Zokufa on board as he took over the reins as Chief Executive & Registrar. No stranger to the healthcare environment, Dr Zokufa has served in numerous roles in the public and private health sector, including serving as Managing Director for the Board of Healthcare Funders (BHF) of Southern Africa, where he served for almost 11 years; and Registrar for the Medicine Control Council. He played a key role in the establishment of the Medicine Pricing Committee. He is currently serving on Work stream 4 on the Role of Medical Schemes in a National Health Insurance (NHI) environment. Dr Zokufa is a registered Pharmacist and Specialist in Clinical Pharmacokinetics.

Dr Zokufa has also served in Senior Management positions within the public health sector at both the Provincial and National Department of Health, and he has also worked as a lecturer at the University of Fort Hare, the University of Pretoria, and the Harvard School of Public Health. He holds a Bachelor of Pharmacy from the University of the North, a Doctor of Pharmacy and Post-doctoral Fellowship from the University of Minnesota, and a Diploma in Health Management from the University of Cape Town.

CMS News interviewed Dr Zokufa to share with the readers some insights on his vision for the CMS. The interview with the new Registrar is captured below.

Q: What are the key lessons learnt from your exposure to all these environments, that you can share with the CMS’ various Stakeholders?R: What I would like to point out to our Stakeholders is the fact that it is imperative for all South Africans, regardless of their background, not to have to suffer when it comes to access to healthcare services. Suffering happens in different ways depending on where you source your healthcare services. The bulk of the South African population, that is about 84%, is utilizing public healthcare services, compared to about 16% of the population that has access to private healthcare services. Both sectors are not functioning well currently, albeit for different reasons. If you look at the total budget available in the public and the private healthcare sector, you will realise that there is no reason why the country does not have a good

quality, unified healthcare service for citizens.

With more than 20 years’ involvement in the public health sector and about 10 years in the private health sector; and having been involved in the Medicine Pricing Control Committee which led to the introduction of the medicine price controls in South Africa, one feels that a lot can be done to make healthcare services affordable for all citizens, particularly with regard to surgical, pathology, and the utilization of medical devices in various forms. Right now a small constituency is controlling a big share of the healthcare budget. There is absolutely no reason why this should be the case, and that is why some of us welcome the Competition Commission’s Health Market Inquiry.

Q: Government is moving towards the introduction of universal healthcare for citizens, with the proposed NHI as a vehicle for ensuring access to healthcare by all citizens. Given this development, how do you see the role of the CMS going forward? R: Even though as a country we have managed to establish efficiency, quality and safety principles in the public health sector, one is convinced that adherence to such principles does not necessarily make a huge impact in a sector where access to pharmaceutical services comes at a very high cost for citizens. As already outlined by the Minister of Health, supported by literature from the World Health Organisation (WHO), universal care is what we need to achieve as a country. The fact however, is that we cannot achieve universal care without a unified pool of a funding system. Section 27 of the Constitution of the Republic of South Africa, and the National Health Act (NHA) makes provision for the promotion of access to healthcare by citizens. The White Paper on the National Health Insurance (NHI) talks about the pooling of resources to enable the country to achieve universal healthcare.

Dr Humphrey Zokufa

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Clearly the current two tier healthcare system is not working well. The healthcare rand is fragmented in the two systems and that, is compromising us from structuring the healthcare system into a unified well-resourced entity that is able to prudently procure from the provinces. The establishment of the NHI, which I fully support, is aimed at pooling the healthcare resources, about R3 billion altogether, in order to be able to prudently plan for the healthcare needs for 55 million people in the country, through strategic procurement. Right now this is not achievable due to the fragmented approach. Having said this, it then becomes important in my new role as Registrar of the CMS, to take cognizance of two factors, i.e. the provisions of the Medical Schemes Act (MSA) with regard to the provision of regulatory oversight for the industry; as well as pay attention to what the government is ushering in as the national policy for the healthcare sector, which is the NHI. The challenge that exists at the moment is the fact that the NHI has not yet been enabled as an Act of Parliament. Currently the MSA does not adequately cover the tenets of the NHI. In view of the above, one must find a way to regulate the industry in terms of the current MSA, while also finding ways of steering the industry in the direction of the NHI. Consideration must at the same time be made to ensure that one must not contravene the provisions of the MSA with regard to the function of the CMS. Whatever we do at the CMS must be within the context of section 7 of the MSA. For me the big challenge is to make sure that the industry is adequately regulated in terms of the MSA, but at the same time steer the industry in the direction of the NHI. It is important that we look at ourselves as a strategic body that has been established by the MSA to play a meaningful role in the national activities which the National Department of Health (NDoH) is embarking on to establish the NHI.

Q: The medical schemes industry can be regarded as a fairly well established industry in SA, what would you say are the industry’s strong features that can be harnessed towards quality healthcare services for all citizens?R: More than twenty years, with major changes provided for in 1998 through the MSA, the private healthcare industry is well established with lot of experience, skill and expertise to manage healthcare financing as it relates to the payment of healthcare services, interaction with various service providers and medical schemes members. These are expertise that cannot be lost, it is a national asset and should find means of optimum utilization in the establishment of the NHI – this is provided for in the Green Paper as well as the White Paper.

Q: And what would you say are the areas where there is a need for improvement for the industry, in order to align to the healthcare aspirations of all South Africans?R: The industry needs to be relevant so that it can be needed when establishing the NHI.

Q: There are those who are sceptical regarding the government’s ability to (1) afford the cost for implementing the NHI, (2) efficiently manage the roll-out of a policy with such a massive program. What is your response in this regard? R: Improvement has to occur on the supply side of public sector healthcare provisioning. We believe that this has to be regulated so as to exert pressure on healthcare costs. The benefit structure also has to be looked at. The NHI provides a comprehensive list of benefit packages that are not limited to the list of disease. There is no need to be sceptical. We need to pool together the resources that are already available in the public and private health sector, in order to ensure universal healthcare for all citizens.

Q: What are your views on the current scenario with the country’s dual healthcare system? Is it sustainable?R: The current system is not sustainable, in fact, it is on the brink of collapse. There is the challenge of shrinking membership, increasing contributions, scheme deficits, and the pool is not growing. There is nothing that points to sustainability.

Q: One can say the political will is there for the introduction of the NHI, what else is needed going forward? R: We need buy-in from the majority of South Africans, as well as a good understanding of what is needed going forward.

Q: With the kind of insight that you have so far, what would you say is the direction that medical schemes should be positioning themselves, towards participation in an NHI environment?R: Schemes and other role-players in the medical scheme industry need to positively position themselves to be part of a pool. They must accept that the path that we are currently on is leading to a cliff. It is important for the industry to fully understand why the government is introducing this policy, which is to save the situation and ensure sustainability. The schemes must ask themselves the question: where are we leading our members to? Schemes and other role-players must embark on strategic initiatives that will make them part of the NHI formation, in terms of Work stream 4 on the Role of Medical Schemes in a National Health Insurance (NHI) environment.

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The legislative mandate One of the oversight roles for the Council for Medical Schemes (CMS) relates to the adjudication of complaints lodged by beneficiaries against their medical schemes. In line with the Medical Schemes Act, 131 of 1998 (the Act), the adjudication of complaints lodged by medical scheme beneficiaries against their schemes is a key element towards the protection of the interests of medical scheme beneficiaries, and ensuring that all complaints raised are handled appropriately.

This includes complaints resolution mechanisms at medical schemes’ level as well as providing members access to complaints resolution mechanisms at the Registrar’s office and appeals processes.

Section 29(1)(j) of the Act stipulates that the rules of medical schemes should make provision for the settlement of complaints and disputes. This means that all medical schemes should have internal complaints resolution procedures available to members who wish to lodge complaints against their medical schemes. Schemes are required to make members aware of the existing internal complaints resolution procedures, which should be easily accessible to all members.

Member complaints can serve as a gauge for administrative / operational short-comings, and

therefore provide schemes with an opportunity to take corrective measures where applicable; it is therefore always beneficial for schemes to deal adequately with any complaints before they are escalated to the CMS.

Section 7(d) of the Act empowers the CMS to investigate complaints and settle disputes in relation to the affairs of medical schemes. The process for the investigation and resolution of complaints is set out in section 47(1) and (2) of the Act. In line with these provisions, all complaints and disputes are handled impartially and objectively by the Registrar’s office.

The CMS’ complaints adjudication process involves the application of case law, the contemplation of registered rules, as well as other relevant legal principles. The principles of fair administrative justice underpins the decision-making process, with all parties afforded an opportunity to make representations.

The determinations made by the Registrar’s Office in relation to complaints are appealable to the Council in terms of section 48 of the Act which provides for three months’ period of filing appeal papers.

Adjudication of member complaints by the CMSby Thembekile Phaswane, Senior Manager: Complaints adjudication

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Investigation and resolution of complaints The CMS adjudicates all complaints lodged against the different entities regulated under the Medical Schemes Act, i.e. medical schemes, administrators of medical schemes, managed healthcare organizations and brokers / brokerages.

The number of complaints received by the CMS has continued to increase over the years. In 2015 the number of complaints increased by 12% compared to the previous year, with an average of approximately 424 complaints received per month.

Complaints form an integral part of a medical scheme’s internal operations, and are a good measure of the effectiveness of services rendered to members by the schemes. Against this background, complaints are viewed as an early-warning tool which highlights operational inefficiencies in systems, people and processes of the regulated entities. They provide insight into current and/or potential problems within the regulated entities especially where the conduct of such entities is found to have either been unfair to members and / or contravened certain provisions of the Act.

A large number of complaints are dealt with in line with the processes set out in section 47 of the Act. There are however, certain complaints which are resolved through mediation involving an independent accredited entity outsourced by the CMS to provide mediation services. The participation of parties in the mediation process is voluntary, the settlement reached is without prejudice and does not set a precedent for other matters.

Common types of complaints received by the CMS in 2015 Some of the common complaints received by the CMS in 2015 related to the short-payment of Prescribed Minimum Benefits (PMBs) in contravention of the Act; payment of PMBs from the members’ medical

savings accounts; unreasonable delay in processing and paying accounts; as well as unsatisfactory general customer service to members.

Most contraventions of Regulation 8 which resulted in members being exposed financially, related to complaints against the Genesis Medical Scheme. The view held by Genesis Medical Scheme, which I must hasten to state was not founded in law nor in the Scheme rules, was that it was entitled to decline funding the treatment of PMB conditions if such treatment was rendered at a private hospital / facility. The fact that this incorrect interpretation of the legislation was finally resolved by our

courts in the matter between The Council for Medical Scheme v Genesis Medical Scheme (2015) SCA 161 (16 November 2015) does not provide any comfort to both the Regulator and members of Genesis Medical Scheme as the Scheme continues to disregard the court pronouncement and still declines funding members accounts for services rendered at private hospitals. In this regard, all complaints

received after the court judgment, which shows persistent disregard of the law and the Supreme Court of Appeal judgement were monitored and escalated to the Compliance and Investigation unit and Legal Services for corrective action to be taken against Genesis Medical Scheme.

The CMS is concerned to note that some medical schemes were still paying accounts for PMBs from the medical savings account despite the fact that this contravention has been communicated to the medical schemes industry on numerous occasions. Regulation 10(6) of the Act prohibits the payment of PMB accounts from the medical savings account. It is important to note that the reasons furnished to the Registrar’s Office regarding this contravention was that it was an “administrative

“The CMS is concerned to note that some medical

schemes were still paying accounts for

PMBs from the members’ medical savings account

”

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error”. The accounts concerned were reprocessed and paid in accordance with the provisions of the Act. The Registrar’s Office made a reasonable conclusion that this was a deliberate contravention of Regulation 10(6). Appropriate measures are being taken against the medical schemes concerned.

The abrupt cancellation of the Vmed administration contract by the Spectramed Board of Trustees and the transfer of the administration of the Scheme to Agility Health (PTY) Ltd resulted in an influx of complaints from members and healthcare providers. The majority of complaints related to the inordinate delays in the payment of accounts, and that some accounts were paid from the wrong benefit allocation. The decision taken by the Spectramed board was not in the best interest of members of the Scheme and certainly not in terms of the fiduciary duties imposed on it by section 57(4) of the Act, as the board failed to ensure that proper control systems are employed by or on behalf of the medical scheme. The members of the board further failed to ensure that the operation and administration of the scheme comply with the provisions of the Act. The Complaints Adjudication unit alerted the Compliance and Investigations unit about its findings against the Scheme, and the negative impact the administrative failures had on members of Spectramed.

Unsatisfactory customer service was another category of complaints that was on the

increase in 2015. In this instance, members complained about a wide range of issues ranging from their correspondence not being responded to; members’ telephone calls not returned, resulting in them making multiple follow-ups; dissatisfaction with their medical schemes’ refusal to escalate matters to higher authorities; and membership certificates not being issued after termination of membership.

The issue of customer service highlighted gaps in member communication; lack of adequate training of all relevant staff, coupled with lack of appropriate skills / expertise; as well as gaps in the internal follow-up procedures. The Registrar’s Office hopes that all issues raised by members pertaining to customer service have highlighted the need for medical schemes to conduct a root cause analysis of complaints with a view of addressing the source of the complaints, thus avoiding the repeat of similar occurrences in the future.

Inefficiencies in various internal systems filters down to members who, in turn, raise the alarm through complaints, and if members’ complaints are not handled at medical schemes level, then the schemes lose an opportunity to engage with members directly. Continued member dissatisfaction can have adverse impact on a scheme, including loss of membership, and the perpetuation of a negative reputation for the scheme.

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The Appeals Committee The Council for Medical Schemes (the Council), was established as a statutory body tasked with regulating the medical schemes and associated entities, in terms of the Medical Schemes Act 131 of 1998 (the Act). One of the key functions for the CMS is to investigate complaints and settle disputes in relation to the affairs of medical schemes, in line with section 7(d) of the Act. In order to give effect to this provision, the CMS has established an Appeals Committee – as a committee of the Council which consists of members who have expertise in the field of law and medicine.

The Appeals Committee is a dispute resolution forum set up to handle appeals from medical schemes and members of medical schemes. All member complaints are first dealt with at scheme level and if a resolution is not reached, members can lodge complaints in writing to the Registrar of the CMS for adjudication, in line with section 47 of the Act. Complaints that cannot be resolved by the Registrar are referred to the Appeals Committee for resolution. These include decisions made by the Registrar where any of the parties involved is not satisfied with the outcome.

High Court clarification on interpretation of Section 48 of the ActFor many years the Appeals Committee of the Council was approached by way of section 49 of the Act for lodging appeals against decisions relating to section 47, which deals with complaints or disputes. This position was also supported by the decisions of the independent Appeal Board, established in terms of section 50. Section 48 (in contrast to section 49) was considered applicable to decisions made by dispute resolution forums of medical schemes. This means that whenever a party – usually a member of a medical scheme – was dissatisfied by an outcome of his / her medical scheme dispute resolution forum, such party could approach the Council by way of section 48. The challenge with this approach is that not all medical schemes have dispute resolutions forums.

The Council’s interpretation of sections 48 & 49 was finally put to the test before a High Court in

order to get clarity on the matter. The Western Cape High Court in the matter between Genesis Medical Scheme v Chairperson of the Appeal Board, Council for Medical Schemes & Others finally put the matter to rest and clarified for all parties the correct section in the Act that has to be applied when approaching the Council for an appeal particularly in relation to complaints lodged pursuant to section 47.

One of the difficulties that have been faced by parties contending over the interpretation of sections 48 & 49 have been the nuanced structure of these sections themselves. This - it is submitted - led inevitably to differences of opinion in their interpretations. The Western Cape High Court, per Davis J, understood language to be contested terrain, and that regardless, used the safe old-age wisdom of contextual interpretation to statutory provisions. While the court admitted that it was possible to infer that Section 49 can be applied to every decision taken by the Registrar, including decisions relating to resolution of complaints as defined, a better interpretation would be one that takes into context what it called the “structural elements” of the Act and which gave an overall meaning to the sections concerned. Taking consideration of all the relevant sections the court was convinced that section 47 of the Act empowers the Registrar to resolve complaints, and that appeals against such complaints must be lodged in terms of section 48.

Section 50(1) establishes an independent Appeal Board consisting of up to three (3) members which is a chaired by a person appointed on account of his / her knowledge of the law. The other two members are appointed on account of their knowledge of medical schemes. Decisions of the Appeals Committee can be appealed against at the Appeal Board. The aggrieved party must lodge his/her appeal with the Appeal Board within 60 days after the date on which the decision on the matter that is subject to appeal, was taken. A prescribed fee must be paid to the Registrar prior to the lodgement of the appeal by the aggrieved party.

by Khayalethu Mvulo: Council Secretariat

Complaints and Disputes Appeal Process

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The Council for Medical Schemes (CMS) has a new champion for the Prescribed Minimum Benefits (PMBs) review project in the person of Dr Sipho Kabane, who joined the CMS as Senior Strategist on 1st July 2016. A Senior Health Manager with 30 years’ experience and an outstanding track record in managing province-wide health service provision programs with a focus on quality, reform and continuous improvement, Dr Kabane brings with him a wealth of experience that is expected to add value towards the overall execution of the CMS mandate. Prominent on his plate at the moment, is the implementation of PMBs review project.

The much anticipated PMB review initiative is expected to help clear some of the grey areas, and reduce the volume of complaints related to payment for PMB conditions. A considerable number of complaints handled by the CMS relates to the payment of benefit for the treatment for medical conditions affected by the PMBs. In some instances this is due to the lack of proper understanding of the requirements and conditions for PMB benefits on the part of the beneficiaries. In certain instances however, the complaints are a result of some of the schemes deliberately feigning ignorance and avoiding their responsibility to pay for healthcare services for members’ PMB related conditions.

According to Dr Kabane, the PMB review project is important in order to among others, bring the definition for the PMBs in line with current healthcare best practices; and ensure that the PMBs are clinically effective, affordable and cost effective. The review process which is prescribed in the Medical Schemes Act, 131 of 1998 (the Act) is an important initiative that assists to clear any uncertainties in the interpretation and implementation of PMBs by all key stakeholders. In order to pull off this important task, the CMS is reinforcing its capacity through the utilisation of internal and external clinical expertise.

“The rationale for the accelerated PMB review and benefit definition project is to ensure that this legal requirement is expeditiously complied with, and that the CMS is able to effectively regulate the industry in the transition towards the NHI dispensation,” Dr Kabane points out. The key aspects of the review process will therefore include:• The development of a robust inclusion,

exclusion and justification criteria for the PMB benefit package;

• Ensuring that the package incorporates basic primary healthcare services including health promotion and disease prevention;

• The Development of a PMB package that takes into account the increasing burden of disease with a specific emphasis on the maternal and child health; HIV, TB, Non-communicable diseases and injuries;

• Ensuring that the final PMB package that will be recommended is as far as possible aligned with the anticipated basic NHI package. This initiative will therefore be a joint effort between the CMS and the NDoH, with support and inputs from all key industry stakeholders;

• Ensuring that the definition process as far as possible specifies the preferred service provider and the setting. In instances where services are efficiently provided by the public service platform, they will be so defined; and

• All the work that was previously done on the PMBs including the proposed regulations and the Code of Conduct will be updated and revised as part of the current review process.

Under the leadership of the Senior Strategist, the Clinical unit provides an internal clinical consulting

PMBs review expected to clear grey areas and reduce complaints

Dr Sipho Kabane

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service to the Complaints Adjudication and other units within the CMS, in order to assist in the efficient and expeditiously resolution of member complaints received by the CMS. The capacity to improve the turn-around times for referred complaints is also being increased through the appointment of new clinical experts.

The training of all stakeholders regarding new developments in the PMBs sphere is another key function that the clinical unit will pay particular attention to, in order to minimise complaints.

“The PMB review project is co-owned by the CMS and the National Department of Health (NDoH). The project will adopt a consultative process approach where all the key stakeholders will be provided with an opportunity to make contributions. The planning for this processes has already started, and a detailed roadmap will be issued to all stakeholders. We anticipate that if there are no undue delays in the process, this effort should deliver its final products in the second half of the 2017/18 financial year,” said Dr Kabane.

A diligent scholar, Dr Kabane’s academic qualifications include: PhD: Health Systems (University of Pretoria); MPhil: Economic Policy (University of Stellenbosch); MBA: Heriot-Watt University (Edinburgh Business School), Edinburgh, UK; MB ChB: Medicine & Surgery (Medunsa/Sefako Makgatho University); BSc: Major in Chemistry & Mathematics (Fort Hare University). He holds several international diplomas in health systems strengthening, financing and management. Among his other key responsibilities at the CMS, Dr Kabane is tasked with overseeing the CMS’ activities in support of the NHI and the Competition Commission’s Health Market Inquiry; the benefit definition project; and the Medical Schemes Amendment Bill. Dr Kabane’s overall vision for his office is to provide support for the CMS’ regulatory oversight role through:• Effective co-ordination of the CMS inputs

towards the National Health Insurance work-stream processes.

• Effective co-ordination of the CMS’ responses to the Competition Commission’s Health Inquiry.

• Efficient clinical support to the Complaint’s Adjudication Unit and other business units within the CMS.

• The provision of an effective communication channel between the CMS and the NDoH in order to ensure effective sector regulation and national policy development and implementation.

• Playing a key role in the development of strategies that will enable the CMS to fulfil its role and mandate in the current and future dispensations.

In 2001 Dr Kabane left a successful private general practice in Welkom and Odendaalsrus in the Free State Province to join the public health services at the Provincial Department of Health in the Free State. While in the province, he also served as a General Manager for the Academic Health Services Complex (including Universitas Hospital and Psychiatric Complex). As part of his responsibilities, he provided technical oversight to the Universitas and Pelonomi Hospital Co-Location Project - a case study which sought to address the fragmentation and duplication of service delivery between the public and the private sector. Under his leadership, this Public-Private Partnership (PPP) initiative enabled the hospital to generate much needed revenue from the private sector.

Between 2010 and 2015 Dr Kabane was appointed as the Provincial Head of Department and Accounting Officer in the Free State and Limpopo provinces respectively. He has also worked for the National Department of Health where his responsibilities included the identification of poorly performing provincial hospitals in line with the Department’s objective to strengthen and improve the public sector health systems. He also facilitated the rollout and institutionalisation of the National Quality Core Standards throughout the provinces, including the provision of training on hospital management. Through his involvement in the implementation of the “Ideal Clinic” programme, he has also contributed towards the improvement of the quality of primary healthcare services level across the country.

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Momentum Health is committed to treating all members fairly and consistently in line with its service delivery values which include: innovation, integrity and compassion. The provision of appropriate and adequate systems to accommodate timeous settlement of claims and prompt response to queries, complaints and disputes, is a key

focus for the organisation.

When a medical scheme aims to provide the best possible service to its members, processes for handling queries and complaints are significantly important. Whether the problem is system related, caused by human error or simply requires information to be shared, immediate and effective resolution is paramount.

The first point of contact for members experiencing

concerns regarding their medical scheme membership is usually the member call centre. Momentum Health’s aim is for the first point of contact to be the final one too.

In order for us to ensure that the call centre service levels remain of a high standard, emphasis is placed on ensuring that the call centre staff are equipped and well trained. No member looks forward to interacting with someone who doesn’t know what they’re doing or doesn’t have the skills or know-how to resolve their query, or speedily process their request.

Momentum Health’s administrator has successfully adopted the following approach to help ensure call centre competence among our call centre agents:• Carefully recruiting the correct calibre of service

agents.• Detailed training of service agents, which includes

in-depth training on the medical scheme’s products, systems and relevant legislation.

• Having proper Quality Assurance systems in place.

A comprehensive Quality Assurance approach assists Momentum Health to identify the reasons for escalated queries, poor service ratings, and repeat callers. This allows for pro-active agent-specific training, as well as system and process enhancements to improve service delivery.

We also ensure that all members are aware of their right to complain, and share information on the complaints, appeals and disputes procedures through various communication channels. Any member may lodge a complaint or dispute, either in writing or via the scheme’s dedicated toll free complaints contact number. Should a member believe that a complaint or dispute has not been adequately dealt with using the normal query process through the scheme’s call centre, the following process may be followed to have the complaint or dispute reviewed:• The member should firstly write to the Principal

Officer providing details of the complaint or dispute. On receipt of a request to review a complaint or dispute, the Principal Officer will investigate and respond to the member in writing.

• Should the member not be satisfied with the decision taken by the Principal Officer, the member may request that the decision be reviewed by the scheme’s Governance and Remuneration Committee, in the case of governance issues, or the scheme’s Clinical Risk and Governance Committee in the case of clinical issues.

• Should the member not be satisfied with the decision taken by either of the above committees, the member may request the Principal Officer to convene a meeting of the scheme’s Disputes Committee, set up in terms of the Medical Schemes Act.

As much as the scheme will endeavour to successfully resolve a complaint through the procedures outlined above, an aggrieved person still has the right to appeal to the Council for Medical Schemes against any decision taken by the scheme.

Momentum Health’s service offering is underpinned by a sincere passion for service excellence and recovery, and the outcomes are geared towards strengthened relationships and satisfaction. The quest for service excellence is clearly demonstrated in the outcome of an annual independent South African Customer Satisfaction Survey, where various medical schemes’ members participated. Amongst others, the survey sought to determine how effectively member complaints were being handled by the different schemes. The results, published earlier this year by SACsi, ranked Momentum Health highest amongst the surveyed schemes in terms of its complaints handling ability. This outcome is one of the things that illustrate Momentum Health’s commitment to provide excellent service to members.

From Complaints to Compliments with Momentum Healthby Tony van den Bergh, Chief Executive and Principal Officer: Momentum Health

Tony van den Bergh

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Conflict is inevitable. The way in which you deal with it determines how personal and professional relationships, and ultimately your reputation will be affected. Nelson Mandela once said “If you want to make peace with your enemy, you have to work with your enemy, then he becomes your partner.” Effective dispute resolution aims to achieve exactly this outcome.

There are three main categories of dispute resolution processes that parties can consider, namely:• Adjudication by a public authority;• Private decision making by the parties involved;

and• Private adjudication by a third party.

The first category refers to litigation in a court or a formal decision making process by an administrative body like the Appeal Board of the Council for Medical Schemes (CMS), as an example. It is common knowledge that litigation can be time consuming and expensive as cases can be drawn out for years, during which time you have to pay a number of legal bills from attorneys and advocates.The second category refers to informal discussions between parties in order to reach a mutual agreement. This is usually done through a structured negotiation process or through mediation. In the latter instance, an independent mediator is appointed to facilitate the process but the outcome is totally dependent on the parties that are involved.The last category refers to a scenario where a third party will investigate a matter and make a finding or recommendation. Examples of this will be arbitrations like we have in the Commission for Conciliation, Mediation and Arbitration (CCMA), the Health Market Inquiry, and other commissions of enquiry.

Alternative Dispute Resolution (ADR) is a collective term for all the mechanisms that can be used to resolve a dispute without going to court. The benefits of ADR is that it is not only cost-effective and time efficient, but also less intimidating as the process is informal and private. The parties decide on the most appropriate way to resolve the dispute. Due to the benefits mentioned above ADR clauses are widely used in commercial and private agreements, and even included in legislative provisions across a number of industries. The King IV Report on Corporate Governance also recommends that boards implement ADR principles as part of their

dispute resolution policies.As the regulator of the medical schemes industry, the CMS also makes use of the ADR approach, which has proven to be very effective in the resolution of disputes between members and their medical schemes. In terms of section 29(1)(j) of the Medical Schemes Act (the Act) every medical scheme must provide a mechanism for dealing with disputes in its rules which are registered with the CMS. The provision for ADR in a medical scheme’s rules allows for flexibility in dealing with disputes, which can either be handled through an independent disputes committee or an in-house structure.

If a member is not satisfied with the outcome of a dispute case handled by a medical scheme, he or she can lodge a complaint with the Registrar in terms of section 47 of the Act. After the Registrar has issued a ruling, any aggrieved party has the right to lodge an appeal in terms of section 48 of the Act. Due to the large number of appeals waiting to be heard by the Appeals Committee of Council, the CMS has identified mediation as an appropriate way to try and resolve disputes, or narrow down the issues in dispute, before the hearing. According to the Centre for Effective Dispute Resolution (CEDR) “mediation is a flexible process conducted confidentially in which a neutral person actively assists parties in working towards a negotiated agreement of a dispute or difference, with the parties in ultimate control of the decision to settle and the terms of resolution.” A simple way of putting it is that the aim of mediation is to find a win-win situation to the dispute for both parties.

Past experience has revealed that some of the dispute matters that have gone through extensive dispute resolution procedures at scheme level and at the CMS, ended up at the appeals hearing where they were either settled or ultimately withdrawn. The trend has been that as soon as a matter is revisited by another independent person and the parties have had the opportunity to be heard in person, the issues are resolved. Based on this observation, the CMS embarked on a pilot project to investigate the benefits of mediation in the medical schemes industry in 2014. The Pilot project proved to be a success and as a result, matters are now regularly identified and referred for mediation by independent mediators. Almost 90% of all matters referred for mediation are settled through this process. The mediation approach is aimed at restoring strained relationships between members

Alternative Dispute Resolution for complaints and disputesby Alicia Schoeman, Legal Advisor: Council for Medical Schemes

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and their medical schemes in a manner that is much cheaper and quicker than the appeal hearings and/or litigation process. The settlements that are reached are confidential. The process is also voluntary and cannot be forced on any of the parties.

Due to the fact that different medical scheme members are located throughout the country, the mediation process is conducted telephonically and the costs incurred are funded by the CMS at a pre-negotiated rate. The function of the mediator is to explore the underlying needs and interests of the parties and to then propose alternative solutions that will address the problem. A reality check is often necessary to make sure that the expectations of the parties are reasonable as well as achievable. At this stage the parties are also enabled to identify the root causes of the problems instead of only dealing with symptoms that will likely be repeated in the future.

It is only the matters that could not be settled through the mediation process that are then enrolled for hearing before the Appeals Committee. This helps to lessen the number of cases on the roll and allows the forum to then deal with substantive legal issues.

The success of the mediation project is largely due to the commitment of our stakeholders who are willing to cooperate and explore alternative ways of dealing with complaints. The process also serves as a valuable educational mechanism as it assists members to understand their rights and obligations better, and also for the schemes to understand how they can improve their systems and communication to members. The CMS looks forward to see an increase in the number of disputes being settled through the ADR approach, and to learn more from the lessons associated with it.

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Promoting patient education on utilisation of day hospitals as a cost-effective alternative for services

Patients who undergo surgical interventions are often not enabled to participate in the decision of where they will be treated. This was one of the concerns expressed by the panel of inquiry during a discussion at the Competition Commission’s Health Market Inquiry (HMI).

The discussion concluded that it is the responsibility of the Day Hospital Association of South Africa (DHASA) to negotiate with medical schemes to further its objectives, one of them being to improve day-hospital utilisation. The DHASA estimates that about 13% of all surgical procedures in South Africa are conducted in day hospitals, a significantly lower figure than the international standard of an estimated 70%.

Treating specialists often tell patients to report for a surgical intervention at a specific

hospital instead of informing them about other options and the advantages associated with such alternative treatments, which include potential cost savings. Surgeons are often pressurised by hospital administrators to fill their theatre slots, making it difficult for them to take work to a day hospital where they could treat patients at a substantially reduced cost.

An improvement in day-hospital utilisation would reduce the cost of private hospitalisation, which has been singled out as the main driver behind the fee escalations experienced by the medical-scheme industry in recent years. The graph below reflects the challenges associated with these cost escalations.

Explanation: An item which cost R1 in 2010 will cost approximately R1,50 by 2017.R1 contributed towards medical scheme contributions in 2010 will amount to R1,80 by 2017Private hospital costs equal to R1 in 2010 will amount to R2,50 by 2017.

by Carl Grillenberger, former Chairman: DHASA

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Explanation: An item which cost R1 in 2010 will cost approximately R1,50 by 2017.R1 contributed towards medical scheme contributions in 2010 will amount to R1,80 by 2017Private hospital costs equal to R1 in 2010 will amount to R2,50 by 2017.

Proposed solutionVirtually all medical-scheme patients admitted for short-stay surgical procedures are subjected to managed-care pre-authorisation protocols. Patients have to contact their medical scheme administrator to get authorisation for the procedure to be performed at a certain facility, usually chosen by the doctor.

The HMI panel has now recommended that measures be put in place to ensure that patients are properly informed (by either the referring GP, the treating surgeon or the medical scheme) of the options prior to approving the surgical procedure.The DHASA says that, if patients are enabled to participate in the decision of where they are to be treated, it will be possible to achieve its goal of increasing the number of surgical procedures conducted at day hospitals from the current 13% to 25% within a year, which will make a meaningful contribution to reducing the overall cost of hospitalisation.

Medical schemes regulate the flow of patients to hospitals. A suitable training programme for medical-scheme employees involved in the pre-authorisation process would result in a quick win towards the objective of curbing hospitalisation cost. Training should include that the patient and/or the treating doctor be made aware of:• the patient’s right to be properly informed

about his/her options regarding the surgical procedure;

• the cost and other advantages associated with day-hospital treatment, to enable the medical-scheme staff member to recommend consideration of a day hospital; and

• information about procedures which can be attended to in day hospitals.

This approach may not yield the full desired outcome immediately, but it will be a catalyst for change. In time, change could be enforced by asking the treating specialist to give reasons in writing as to why a patient should be treated in an acute facility instead of a day hospital, as is required if doctors wish to deviate from medical-scheme protocols.

The DHASA is willing to appoint staff to implement training and track progress through a monthly report reflecting the number of additional patients secured via the proposed system, together with the feedback received from the participating medical schemes. The report will be distributed to medical-scheme administrators on a strictly confidential basis.

Advantages of the utilisation of day hospitals for surgical procedures:

Online admission protocols: The HMI panel has recommended the implementation of on-line admission protocols. Reception staff at day hospitals will, in the future, need to be trained to use on-line admission systems and help with the completion of the required admission forms to eliminate delays with the admission of patients on the day of surgery.

Savings: Day hospitals can bring about significant savings for medical-scheme members who use day hospitals instead of traditional acute hospitals.

Day-hospital procedures: An ever-increasing number of procedures can be carried out in day hospitals as a result of evolving surgical techniques. The increasing utilisation of day-hospital facilities across the world is contributing to the transformation of the surgical healthcare industry in terms of a more convenient and cost-effective alternative to hospital-based surgery, for thousands of patients.

Trauma: Patients are not exposed to the traumatic experiences which are often part of an acute hospital.

Shorter recovery period: Day hospitals deal with patients that are healthy and, as a result, patients are not exposed to viruses and/or infections, which often results in shorter recovery periods.

No overnight stay: Patients are treated and discharged on the same day. The arrangement is convenient for patients and parents with small children as they do not have to stay overnight in an unfamiliar environment.

Quality outcomes: Rapid advances in surgery and anaesthetic technologies result in a fast turnaround in a facility designed for only short procedures, to the benefit of patients and surgeons.

Conclusion As stated in the Health Professions Council of South Africa (HPCSA) National Patients’ Rights Charter, all people have the right to participate in the decision-making process on matters affecting their health status. This participation includes the right to receive information on the availability and advantages of healthcare services at day hospitals and the right to choose a facility for treatment. Failure to inform patients of all alternative options constitutes a violation of these rights.

The education of patients regarding the different healthcare options is an important step towards further refining the management of private healthcare in South Africa.

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What are Prescribed Minimum Benefits (PMBs)?Prescribed Minimum Benefits (PMBs) is a set of benefits, which must be covered by each medical scheme as mandated by section 29(1)(o) and (p) of the Medical Schemes Act, 131 of 1998 (the Act). Medical schemes must fund for the diagnosis, treatment and care of PMB conditions in full, without imposing co-payments or using deductibles from a risk pool. The medical savings account may not be used to fund PMBs as mandated by Regulation 10(6). Entitlement to PMBs is not subject to patient plan options or benefit types.

What is covered under PMBs?PMBs cover the most serious and often life-threatening conditions, including the following: • Any emergency medical condition as per the

definition in the Regulations to the Act;• 270 Diagnostic Treatment Pairs (DTPs); and • 26 chronic conditions on the Chronic Diseases

List (CDL)

Although PMBs must be funded in full, the Act allows medical schemes to use certain measures to manage the financial risks that are often associated with the unpredictable health needs of their members. It is extremely important to understand the implications of these measures so as to avoid co-payments being imposed on members.

Financial measures allowed to manage costs related to PMBsDesignated Service ProvidersDesignated service providers (DSPs) are healthcare providers, such as doctors, specialists and hospitals, which have entered into agreements with medical schemes to provide their services to the members of such medical scheme at a negotiated price. Each medical scheme has its own DSPs and using the correct DSP for PMBs guarantees members that their scheme will cover PMB conditions in full (at cost). In cases where a DSP is accessible and available but voluntarily not utilised by the member, the medical scheme may charge a co-payment as specified in the particular medical scheme’s rules.

Medicine FormularyA medicine formulary is a list of medications that the scheme is willing to fund for the treatment of PMB conditions. These formulary lists must be developed using evidence based medicine,

and be cost effective. Formularies are often plan or benefit specific and must be accessible to the members of the scheme at request. If a member voluntarily choose to use medicines not listed on the formulary, the medical scheme may charge a co-payment as specified in the medical scheme’s rules. In instances where the formulary medicine has proven to be ineffective or causes harm or an adverse reaction to a member, provision must be made for appropriate exceptions or substitution without any penalty to the member (Regulation 15I(c)).

Managed healthcare protocolsManaged healthcare protocols must be developed using evidence based medicine and must take into consideration cost-effectiveness and affordability. Medical schemes must provide their protocols to healthcare providers, beneficiaries and members of the public on request. In instances where the formulary medicine has proven to be ineffective or causes harm or an adverse reaction to a member, provision must be made for appropriate exceptions or substitution without any penalty to the member (Regulation 15H(c)).

What doctors can do to ensure that access to PMBs is not delayed, e.g. clear notes, discharge summaries, etc.1. Doctors must adhere to clinical guidelines

and protocols, as well as formularies in the management of medical conditions.

2. They need to write comprehensive, clear and legible clinical notes and discharge summaries. A good clinical record is a valuable asset that assists in the adjudication of complaints and other medico legal matters. This includes letters of motivation, discharge summaries and prescriptions.

3. They need to understand the coding systems and adhere to appropriate use of ICD-10 and procedure codes and modifier codes. The South African Medical Association (SAMA) provides coding courses from which providers and administration companies can benefit. The course should be based on the National Reference Price List (NRPL) of 2006.

What are the common mistakes committed by doctors in motivating for PMBs? 1. Not documenting a full clinical history and

findings at examination and treatment, with the appropriate codes.

PRESCRIBED MINIMUM BENEFITS

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2. Non-adherence to clinical guidelines and protocols, bearing in mind cost effectiveness, affordability and scientifically sound and prevailing level of care in the public healthcare sector.

Complaints processWithin a medical schemeThe Council for Medical Schemes (CMS) governs the medical schemes industry and therefore member complaints should be related to the member’s medical scheme. Any beneficiary or person who is aggrieved with the conduct of a medical scheme can submit a complaint to the CMS, for adjudication.

It is however very important to note that a prospective complainant should always first seek to resolve complaints through the complaints mechanisms in place at the respective medical scheme before approaching the CMS for assistance.

Members can contact their scheme by phone or if not satisfied with the outcome, in writing to the Principal Officer of the scheme, giving her/him full details of their complaint. If they are not satisfied with the response from the Principal Officer, they can ask that the matter be referred to the Disputes Committee of their scheme.

If members are not satisfied with the decision of the Disputes Committee, they can appeal against the decision within 3 months of the date of the decision, to the CMS. The appeal should be in the form of an affidavit directed to the CMS.

Complain ts to the CMSComplaints against medical schemes can be submitted by letter, fax, e-mail or in person at the CMS office from Mondays to Fridays (08:00-17:00). The complaint form is available from www.medicalschemes.com

Complaints should be in writing, detailing the following:

• Full names; • Membership number; • Benefit option; • Contact details; and • Full details of the complaint with any documents

or information that substantiate the complaint.

The CMS’ Customer Care Centre and Complaints

Adjudication Unit also provide telephonic advice and personal consultations, when required.

The CMS’ aim is to provide a transparent, equitable, accessible, expeditious, as well as a reasonable and procedurally fair dispute resolution process. In line with this approach, the CMS will send a written acknowledgement of a complaint within 3 working days of its receipt, providing the name, reference number and contact details of the person who will be dealing with a complaint.

In terms of section 47 of the Act, a written complaint received in relation to any matter provided for in the Act will be referred to the medical scheme. The medical scheme is obliged to provide a written response to the CMS within 30 days.

The CMS shall within 4 days of receiving the complaint, analyse the complaint and refer it to the relevant medical scheme for comments.

Upon receipt of the response from the medical scheme, the CMS will analyse the response in order to make a decision or ruling. Decisions / rulings will be made within 120 days of the date of referral of a complaint, and communicated to the parties.

The Registrar’s Ruling and Appeal to CouncilSection 49 of the Act makes provision for any party who is aggrieved with the decision of the Registrar to appeal such a decision.

This appeal is at no cost to any of the parties.

An appeal must be lodged within 30 days of the date of the decision. The operation of the decision shall be suspended, pending review of the matter by the Council’s Appeals Committee.

The secretariat of the Appeals Committee will inform all parties involved of the date and time of the hearing. This notice should be provided no less than 14 days before the date of the hearing.

The parties may appear before the Committee and tender evidence or submit written arguments or explanations in person or through a representative.The Appeals Committee may after the hearing confirm or vary the decision concerned or rescind it and give another decision as it seem just.

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The Section 50 Appeals processAny party that is aggrieved with the decision of the Appeals Committee may appeal to the Appeal Board.

The aggrieved party has 60 days within which to appeal the decision and must submit written arguments or explanation of the grounds of his or her appeal.

The Appeal Board shall determine the date, time and venue for the hearing and all parties will be notified in writing.

Appeal Board hearings shall be heard in public unless the chairperson decides otherwise.

The Appeal Board shall have the same powers as the High Court, to summon witnesses; to cause an oath or affirmation to be administered by them; to examine them; and to call for the production of books, documents and objects, in order to make a decision on a matter

The decisions of the Appeal Board are in writing and a copy thereof shall be furnished to parties.

The prescribed fee of R2 000.00 is payable for section 50 Appeals.

CMS contact details

Customer Care Centre 0861 123 267 0861 123 CMS

Reception Tel: 012 431 0500 Fax: 086 206 8260

General enquiries E-mail enquiries: information@medicalschemes.comwww.medicalschemes.com

Complaints Fax: (086) 673 2466 E-mail: complaints@medicalschemes.com

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VisionTo promote vibrant and affordable cover for all.

MissionThe CMS regulates the medical schemes industry in a fair and transparent manner and

achieves this by:

• Protecting the public and informing them about their rights, obligations and other

matters, in respect of medical schemes.

• Ensuring that complaints raised by members of the public are handled appropriately and

speedily.

• Ensuring that all entities conducting the business of medical schemes, and other

regulated entities, comply with the Medical Schemes Act.

• Ensuring the improved management and governance of medical schemes.

• Advising the Minister of Health of appropriate regulatory and policy interventions that

will assist in attaining national health policy objectives.

• Ensuring collaboration with other entities in executing our regulatory mandate.

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Goal 1

Access to good quality medical scheme cover

is promoted Goal 2Medical schemes and

related regulated entities are properly governed, responsive to the environment and beneficiaries are

informed and protected

Goal 4

CMS provides strategic advice to influence and support the

development and implementation of

National health policy

Goal 3

CMS is responsive to the environment by

being a fair, transparent, effective and efficient

organisation

The CMS Strategic Goals

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CMS NewsCOUNCIL FOR MEDICAL SCHEMES

This is a publication by the Council for Medical Schemes (CMS)

Postal addressPrivate Bag X34

Hatfield0028

Physical addressBlock A

Eco Glades 2 Office Park420 Witch-Hazel Avenue

Eco ParkCenturion

0157

Call 0861 123 267 orvisit www.medicalschemes.com

for Medical SchemesCouncil