Possible reasons why your medical scheme is not paying your bill


Cape Town – There are few things as frustrating as trying to negotiate the administrative labyrinth of a medical scheme. But one thing that is worse, is having to pay the bill yourself.

Chat to any medical scheme member, and you will find that just about everybody has a story to tell about a bill they expected to be paid, and which was not. But contrary to popular belief though, the fault does not always lie with the scheme – sometimes members do not follow the correct claiming procedures or rules, and sometimes the fault lies with the doctor’s billing practices.

These rules can sometimes be very difficult to understand, as I recently found out when it took me three months to sort out a hospital bill for a relative – and after all these years I know my way around medical scheme processes. (It eventually turned out they needed two quotations for a piece of medical equipment, and not just the one.)

This is by no means a comprehensive list of possible obstacles, but the things below could give you some idea of what the problem might be. Sometimes you could be lucky in that a service consultant might be able to give you an answer in five minutes, or you could struggle for three months, as I did.

Also remember that things are different for every option, and within every medical scheme, but there are certain rules everyone needs to adhere to. Mostly, schemes will tell you the reasons for non-payment. If you disagree with them, read the small print in your benefit schedule, and if you feel you still have a case, you can contact the Council for Medical Schemes. Here’s more detail about the complaints procedure.

Possible reasons for non-payment of your claim to the scheme:

Your membership contributions are not up to date. Make doubly sure that your debit order has gone through, or that your employer has indeed paid the money over to your medical scheme if it gets deducted from your salary. Non-payment of contributions can lead to non-payment of claims.

The cut-off date for that claim has expired. You have to send a copy of the account to the medical scheme before the end of the fourth month from the last date of the service rendered. The date must be on the account. So if you see the doctor on the 20th of January, you can submit that account until the 20th of May. After that, the claim will not be settled.

Your benefits have been exhausted. If something has to be paid from your medical savings account (MSA), and there are no funds left, you may be in a self-payment gap and you have to pay the bill yourself. Or you don’t have day-to-day cover and your treatment was not in a hospital.

There are strict regulations on benefits (such as how much you can spend on dentistry, new glasses and so forth) and if that has been exhausted, your scheme will not pay. Read the small print carefully when you choose an option on the scheme.

There is no referring doctor named on the specialist’s account. You cannot refer yourself to a specialist – a GP has to do that, if you want the scheme to pay any portion of the bill. This is to prevent people going straight to a specialist when a GP might have been able to sort out their problem at a fraction of the cost. Repeat visits to a specialist after that will always still have the name of the original referring doctor on the account.

Your membership number is not on the account. Unless the right membership number is on the account, the scheme has no proof that it was you who had the treatment. This is especially important to remember if you change schemes. Make sure the doctor’s records are changed to contain the new information.

The condition you were treated for is not a PMB. Certain hospital procedures are not prescribed minimum benefits (PMB), such as in the case of certain cosmetic surgeries, or some rare conditions. Check with your scheme before you go for treatment. Also, if you go to the doctor, and the condition with which you are diagnosed is not a PMB, you will have to pay the account yourself, if your benefits have run out or your scheme does not cover you for diagnosis of certain conditions.

You are still subject to a waiting period. When you join a new scheme, you can be subjected to a waiting period of three months before you can claim (this excludes hospital emergencies such as in the case of an accident). Also, based on your medical history, your scheme can exclude you from treatment for certain conditions for a maximum of 12 months. If you claim during that time, the bill will not be settled.

Your prescribed medication is not on the medicines formulary. Schemes use a medicines formulary (list of approved medication – often generics) to determine which chronic medications they will fund. This can either be a list of medications, or a rand value per condition. All medical schemes have to pay for the treatment of 25 chronic conditions.

Ask your pharmacist for the generic medication – it might save you lots of money.

You did not get pre-authorisation before your hospital visit. Unless it is an emergency, in which case the hospital will contact the medical scheme, you need to phone your scheme before you are admitted to hospital for treatment. Without an authorisation number, the scheme will not foot the bill.

You went to an out-of-network hospital/doctor. Some schemes have network hospitals and network doctors, who guarantee members of certain scheme treatment without co-payments. If you choose to go to another hospital you could be landed with a large portion of the bill. The same goes for private doctors.

The ICD10 codes on the account are not valid. These are diagnosis codes for specific conditions, which your doctor has to indicate on the bill. If there is no ICD10 code, or it is for a condition that is not covered, you might have to pay for this treatment yourself.

The medical practitioner does not have a valid practice number. Before a scheme will pay a medical practitioner, he/she and the practice has to be registered with the Health Professions Council of South Africa. Without that practice number, schemes will not pay the bill.

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