Pensioner wins Profmed medscheme battle

By Chris Steyn

An unemployed man and a community service doctor have been given a lifeline by a medical scheme that had previously denied them payment for additional doses of a “bowel-saving” medication.

Their health and financial plights were brought to the attention of BizNews by retired nurse Nancy Soller.

At the time, she had become engaged in a bitter battle with Profmed over treatment for her son Ross, 33, who was diagnosed with Ulcerative Colitis (UC) last year.

“If my son does not get this drug, he could end up having his whole bowel removed (worst case scenario as it can rupture) if it progresses when in a flare-up.

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“Twice he has been hospitalised, and they do pay for the rescue pack of Revellex in hospital – but you can’t stop there as in my son’s case, he needs two more doses to get him into remission. That is what they won’t pay for. It makes no sense to treat it like this. It’s like giving a first dose of an antibiotic, (and) then saying we won’t pay the rest.

“I can tell you this will bankrupt me, a pensioner, to pay for these medications.”

By the time Soller approached BizNews, she had written to Profmed to say she had found its stance “highly unethical”.

In his reply to her letter, Profmed Principal Officer and Chief Executive Craig Comrie said he had referred the case to the Clinical Executive for review. “We hope your son has been stabilised and that his condition is improving. I understand it is difficult to cope with a relative who is ill.”

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Comrie pointed out that ongoing treatment using expensive biological drugs was only covered on its ProPinnacle option with a 20% co-payment.

“You are well within your rights to not accept our views and appeal any of our decisions with the CMS (Council for Medical Schemes).”

In her response, Soller charged: “You are going against all medical science and harming the patient.”

Declaring that she had no hope of a favourable outcome from the review, Soller wrote: “Your medical/clinical team have already turned us down, and you, as the PO, have the final say with your Board; so waiting for them is another fruitless waste of time and barrier to getting my son the treatment he needs.”

BizNews then wrote to Comrie to inform him that it was investigating the Soller case.

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That same day, Comrie replied to BizNews: “It’s difficult to comment further on the case until I have all the information from my clinical team and expect a report from them as soon as this Tuesday.”

On Tuesday evening, Soller received a good-news letter from Comrie:

“Our Clinical team has reassessed the historical claims information and motivations provided by the treating provider, and I also requested a second review of this from the Medical Advisor.

“Based on the severity of his symptoms and the fact that he has failed all other lines of treatment in the algorithm, the Scheme has taken the decision to approve the request for the additional two doses of Revellex.

“I believe that you will be happy with the outcome and hope that Ross’s condition will improve.”

The second case was that of Eran Taylor, a 25-year-old junior doctor – currently completing his community service year. 

He was diagnosed with Ulcerative Colitis in 2020 and has been hospitalised six times.

“In total, I have received 12 doses of Revellex. I have paid cash for each dose as Profmed has consistently declined to fund this treatment. An appeal was sent by my treating gastroenterologist, and I have sent numerous emails to the chronic department. The answer is always the same – that I need to upgrade my plan to their most expensive one to fund this treatment.”

With his next dose due the following week, Taylor was becoming “quite desperate” to get it funded. “I am also required to pay cash for the admission to the day ward that I require for its administration because Profmed refuses to pay for anything related to Revellex. I have spent well over 100K on this medication, and if continued, it will cripple me financially.”

Taylor received a swift undertaking from Comrie to escalate his query to Profmed’s Clinical team “so I can properly review the details of your concern”.

“Profmed has always relied on clinical experts regarding the legality of our protocols that govern each prescribed minimum benefit (PMB condition). Your case seems very rare, so our protocols rely heavily on this clinical expertise, which is made available to us through various reputable managed care organisations.”

Comrie promised: “In your specific case, I will personally see to it that our clinical team re-evaluates whether you have gone through the initial lines of treatments and therapies to determine if you qualify for exceptional circumstances which drive the funding you request.” 

Three days later, Taylor wrote to BizNews: “Just got some exciting news.”

He shared an email he had received from a clinical pharmacist reading: “Kindly note that the Revellex x3 is authorised on chronic from 31/01/2023 till 11/08/2023 and for renewal thereafter….”

He also shared a letter he had received from Comrie: “I have reviewed the report received from our managed care provider along with the added information that you have provided. Our clinical executive, Justine Lacey, has also confirmed that your history complies with the relevant UC treatment algorithm pertaining to PMB and that, based on your condition, it is an exception management should include coverage of your salvage doses received in January.

“I have asked that she also engage with you to obtain the claims from January 2023 so that we can reimburse you for these.”

In her comment on the successful resolution of both cases, Soller stated: “There is nothing saintly about what they have done; it is what they ought to have done from the beginning.”

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