The Council for Medical Schemes (CMS) is considering outsourcing appeal adjudication to an independent panel.
This detail was included in the CMS’s response the lawyer’s letter sent by the Board of Healthcare Funders (BHF) in February.
The BHF represents around 40 schemes and administrators serving 4.5 million beneficiaries.
In the letter, the BHF accuses the CMS of deliberately sabotaging medical schemes to boost the perceived value of National Health Insurance (NHI).
Read: CMS denies it is sabotaging medical schemes to boost NHI
It also tackles other long-standing disputes, like the delay in implementing a regulatory framework for low-cost benefit options, as well as newer issues, such as schemes announcing 2024 contribution increases and benefit changes before regulatory approval.
Read: CMS invites BHF to collaborate, criticises ‘forum-shopping’ tactics
Another one of the complaints raised in the letter is that the CMS’s appeal processes are ineffective and slow.
“The maladministration of [the] secretariat functions of the Appeal Committee and the section 50 Appeal Board materially hinders access to justice for parties who are compelled to exhaust internal remedies before accruing a right to approach the High Court. The registrar remains unresponsive to the BHF members’ concerns, which effectively renders the appeal process before the council a waste of time to their minds,” the letter said.
Although CMS acknowledges the delay in processes in its response, the regulator argues that the slow progress is caused by the schemes themselves.
The CMS claims that medical schemes have shown little respect for the current appeals processes and have consistently abused them “to the detriment of member interests”.
“Schemes challenge every decision, litigious nature and abusing the appeal processes, resulting in heavy backlogs and taking advantage of suspensory nature of the decisions,” the regulator said in its 31-page response.
The CMS further says that, in practice, “urgent and life-threatening” appeals are being prioritised to the extent that some are brought to the CMS notice by their counterparts, appellants and/or schemes.
According to the regulator, a joint process to develop a seamless and joint standard operating procedure with complaints adjudication is in motion to address issues of referral.
“Council is in a process to explore the possibility to outsource the adjudicative aspect of appeals to a panel that could operate independently and on a weekly basis,” the report reads.
Once implemented, the way appeal resolutions are handled will change: simple cases will have one-person hearings, often resolved through paperwork, while complex medical and regulatory matters will involve three-panel members.
“The Appeals Committee would remain as an oversight governance committee that will oversee the work of the independent adjudicative panel,” the CMS explains.
