Circular 11 of 2023: Entities providing managed care services for which they are not specifically accredited

Introduction

The Council for Medical Schemes (CMS) has observed over time that certain Accredited Managed Care Organisations (MCOs) entered into contracts with medical schemes to provide managed care services for which they have not been specifically accredited for, and which are not indicated on their respective managed care accreditation certificates.

MCO’s should not in any form or manner assume that because they have been accredited for one or a number of services, it is a blanket accreditation which entitles them to provide any other managed healthcare service without having been specifically accredited for it.

Purpose

CMS hereby reminds MCO’s that accreditation for each managed care service (refer to the Accredited Managed Health Care Services document published with Circular 54 of 2022) should be applied for and approved by the CMS before the accreditable managed care services can be offered to client schemes.

The approved managed care service(s) are listed on the MCO’s managed care accreditation certificate and are reflected on the CMS website.

Consequences of MCOs providing / contracting for unaccredited managed care services

Failure to comply with this accreditation requirement may have a detrimental impact on the MCO’s accreditation status and may result in the MCO being directed by the CMS to reimburse affected schemes for any fees received from medical schemes for any unaccredited managed care services rendered.

Download the Circular here.