Medical schemes are getting away with non-payment


The Medical Schemes Amendment Bill and National Health Insurance Bill were recently published. Two of the main features of the Medical Schemes that will affect the public directly are proposals for a fixed tariff for medical service providers, and to scrap co-payments on a defined number of benefits.

Med ClaimAssist, a division of Constantia Insurance Company Limited, welcomes this proposed amendment, as they are especially aware of the problems of short and non-payment by Medical Schemes. Med ClaimAssist offers a specialised service, which assists members when a medical claim is short paid or not paid at all. Since inception, Med ClaimAssist has intervened on 8433 claims and collectively saved clients more than R16 million.

In a recent study conducted by Med ClaimAssist, they found 239 instances of non-payment since March 2018, all of which were Prescribed Minimum Benefit (PMB) emergency cases, where the Medical Scheme simply has not paid. As these are PMB emergencies, there is no doubt that the Medical Schemes are responsible for the payment of these claims. According to David Green, Divisional Head of Health, this is disgraceful. When taking a closer look at this same data, it is obvious that some of the biggest medical aids were circumventing the law to the disadvantage of their patients. And this was by no means only the smallest or unfamiliar Medical Aid Schemes. Simply by looking at percentages paid across the period in question, it is clear that Medical Schemes really aren’t living up to their claims or perceived reputations. Below are the top five worst performing schemes by percentage paid out to members:

17.38% - LA Health Medical Aid (administered by Discovery)
19.48% - Quantum Medical Aid Society
28.85% - Bankmed (Administered by Discovery)
34.42% - TFG Medical Aid Scheme
34.83% - MedShield Medical Aid

In rand-value terms, Discovery Health Medical Scheme has short paid the most – only paying 39.79% of what it should have.

When considering the significant amount members pay to their Medical Scheme every month, it is shocking to think they could still be held responsible for more than 80%, even in PMB emergency cases.

Med ClaimAssist is passionate about ensuring that Medical Aid Schemes meet their promises made to members. Green says there are three broad categories of mistakes leading to non-payment of PMB conditions:

* Errors on the patient's side: for example, the Medical Scheme may have a requirement that health services are accessed through a network of providers known as Designated Service Providers (DSPs). Should the patient access services from a non-DSP provider when they could have gone to a DSP, the Medical Scheme will pay short or not pay the bill at all. This does not apply in the case of emergencies.

* The provider may have made an error: this most commonly occurs when the provider submits an inaccurate or incomplete diagnosis or procedure code on the claim to the Medical Scheme.

* The Medical Scheme could have made an error in processing the claim. It is never easy identifying the root cause of these issues, as the complex sets of rules, benefits and codes, make it almost impossible to ascertain.

Med ClaimAssist analyse their clients’ claims using a claims engine to identify where exactly the problem lies, after which they approach the source, whether a medical service provider or scheme and get the claim paid.

The Med ClaimAssist team believes the conduct of Medical Aid Schemes should not only be better regulated but carefully scrutinised, especially as the bill proposes changes to PMB regulations. This, in turn, will place greater emphasis on primary and preventative healthcare, increasing the importance of ensuring that non-payment does not occur.

Contact Med ClaimAssist on (021) 424 8040, 082 877 0229, or to find out more. Med ClaimAssist is a division of Constantia Insurance Company Limited. An Authorised Financial Services Provider. FSP No. 31111

Alex BaroutsosComment