MPCAM: ProtectHealth Promised To Approve Excess Madani Medical Scheme Claims

MPCAM says ProtectHealth Corp has assured it that panel GPs won’t have to foot costs from Madani Medical Scheme claims that exceed limits, but MPCAM notes that doctors still have to bear losses from medications reimbursed below clinics’ purchase prices.

KUALA LUMPUR, Sept 1 – Panel medical practitioners will not incur extra expenses if treatment costs surpass the threshold set in the Madani Medical Scheme (SPM) that provides fully subsidised treatment to low-income Malaysians. 

While public communications by ProtectHealth Corporation Sdn Bhd, a fully-owned Ministry of Health company which administers SPM, state that the scheme’s benefit limit is RM250 per household, Medical Practitioners Coalition Association of Malaysia (MPCAM) president Dr Soo Tai Kang referenced an RM250 limit per person.

Dr Soo said ProtectHealth informed private general practitioners (GPs) that it would reimburse claims exceeding RM60 per visit, as long as the total subsidy of RM250 per person has not been exhausted, or even a little more than that.

“We were told we will not absorb the loss even if the claim exceeds RM250 subsidy. For example, RM258 – ProtectHealth will still approve the claim,” said Dr Soo in a written response to CodeBlue. 

According to Dr Soo, despite ProtectHealth’s commitment to ensure that GPs don’t bear the loss when it comes to claims exceeding publicly stated benefit limits, doctors may still end up bearing some losses.

This is due to the company’s list of set medication prices for SPM, as some drugs are reimbursed below market price. 

Dr Soo told CodeBlue that this limits the choice of medications at the doctor’s disposal, lessens the duration of treatment the patient receives, and increases patient revisits to clinics. 

“The prices of medications may differ between clinics and ProtectHealth. So, here, the clinic will have to bear the loss due to the difference in purchase price.”

Former MPCAM president Dr Raj Kumar Maharajah said his main concern when it came to SPM was the potential lack of communication with potential beneficiaries over their benefit limits in the scheme.

“The clients must know that they have a certain amount only that can be used, so when the client is aware then the client will not demand too much,” Dr Raj Kumar told CodeBlue.

“[But when patients are not informed], we are stuck. We cannot absorb that cost. So no way we will absorb any cost unless it’s a real poor patient. Emergency, the downtrodden, hardcore poor then yes we do some community services then yes, but other than that, no. 

“If we are going to subsidise everything, it is not our duty to subsidise because we also got our families and our families to feed. We are working to also put food on the table, so if we start subsidising all these things, it will be never-ending and difficult for the doctors.”

Fee Structure: Combined Consultation & Medication (RM60 Per Visit), Investigations (RM50 Per Visit), Therapeutic Procedures (RM50 Per Visit)

From June 15 to December 31, 2023, the SPM benefit limit supports treatment for acute conditions at private GP clinics for eligible beneficiaries and Sumbangan Tunai Rahmah recipients. Under the scheme, households are entitled to RM250 per household, senior citizens aged 60 and above are entitled to RM125, and singles are given RM75. 

Beneficiaries have access to treatments in three categories. The first is combined consultation and medication with a limit of RM60 per visit. This category covers conditions like cough, cold, diarrhoea, vomiting, sprains, strains, headache, and mild trauma. Services excluded from coverage are routine vaccination, health screening, follow-ups for chronic disease, and family planning, among others.

The second category is investigation (point-of-care testing (POCT) or diagnostic procedures) that is capped at RM50 per visit and covers 12 types of tests: full blood count, urine tests (including drug abuse tests), dengue tests, Covid-19 tests, HIV tests, glucometer, electrocardiogram, X-rays, pelvis ultrasound for obstetrics and gynaecology emergencies, speculum examinations, and proctoscopy examinations. 

The final category is therapeutic procedures (excluding basic life support that is reimbursed as per service item without a maximum limit per visit) that is also limited to RM50 per visit. Patients can use the scheme for the following procedures: nebulisation, compression and bandaging for a haemorrhage, immobilisation bandaging, simple wound dressing, wound cleaning and closure, opening of sutures, foreign body examination and straining of the eye, eye irrigation, removal of foreign body, removal of nail under local anaesthesia, evacuation of nail trephination for subungual hematoma, urinary catheterisation and insertion of intravenous cannula and/or Intravenous infusion, initiation. 

SPM – which will be expanded nationwide this month, just three months after its launch last June 15 – was allocated RM100 million by the federal government, lower than Selangor’s RM125 million for a similar scheme, Skim Peduli Sihat (SPS), during its 2016 launch, limited to state residents.

This is the second part of CodeBlue’s series on SPM:

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