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Medical Aid Short Paid Provider’s Bill

Short payment by medical aid is becoming more common these day as more practitioners move away from NHRPL tariffs and charge private rates. Until recently, patients were not aware that they would be faced with a bill above and beyond what medical aid pays for these procedures. However, practitioners are now required by law to inform patients about their higher than medical aid rates before commencing treatments and patients have to sign a consent form indicating that they still wish to undergo treatment at this higher price.



At a time when one in four South African medical aid members can no longer afford cover, how do patients deal with this situation? Medical aid premiums are significantly higher and increasing above the inflation rate every year. Now members are required to pay these premiums and have the funds to settle their doctor and other service providers for the shortfall in payment. Fortunately there are some options that medical aid members can consider to not be out of pocket beyond their monthly contributions.

1. Find a doctor contracted into medical aid

Not all service providers have opted to charge private rates. It may take a little effort on your part as the patient but chances are that there will be some practitioners who charge medical aid rates, and nothing extra. However, you may have to travel out a bit for a practitioner who is contracted into medical aid. The travel cost and inconvenience of consulting with a practitioner who is contracted into medical aid may not be worth the hassle so consider your decision carefully.

2. Get medical aid gap cover

Medical gap cover is a short term insurance policy that pays the difference between what your medical aid pays out and what the doctor/specialist charges. Essentially it pays the difference between medical aid rates and private cash rates.  It costs a few hundred rands a month but will pay 300% above the medical scheme’s rates to ensure that the practitioner is settled in full and you as the medical aid member is not financially inconvenienced. However, it is only for medical aid members and will not pay for the shortfall in out of hospital bills.

3. Negotiate with your doctor

Most practitioners understand the inconvenience of having to pay the difference from what your medical aid short pays. Accounts staff are often faced with complaints and pleas from patients and many are willing to make payment arrangements. Remember that sending your bill to a debt collector is the last step any creditor wants to take, as it is tedious and costly for them as well. Rather speak to the practitioner’s accounts department as soon as possible.

4. Speak to your medical aid

Not every instance of short payment by your medical aid has to do with practitioners charging private rates. At times the issue lies with your medical scheme itself. Errors with accounts capturing, wrong codes inserted by the practitioner’s staff and other administrative problems may lead to the medical scheme short paying the practitioner. Speak to both your medical aid and the practitioner’s accounts department to identify the problem and get it resolved where possible.

5. Watch your annual limits

Although you have to pay your medical aid premiums year round, it does not mean that you will have benefits throughout the year. All schemes have a benefit limit for out-of-hospital treatment and for certain in-hospital procedures. It is important that you as the medical aid member be aware of these limits and utilise services only when you need it.

There is no doubt that the benefit limits are not as high as most members would like it to be, but all too often patients seek medical care unnecessarily leaving them vulnerable when they need the cover. Another problem is that many medical aid members do not read the fine print especially when switching over to cheaper medical aid plans. The limits in cheaper plans are significantly lower.

6. Seek advice from a higher authority

As a healthcare consumer, you have recourse in the event that the medical aid is reneging on their commitment or your doctor is overcharging you. The Council of Medical Schemes regulates medical schemes in South Africa and you can take your case to them should your scheme be treating you unfairly. Similarly you can take the matter to the Health Professions Council of South Africa (HPCSA) if your doctor’s behaviour can be considered unethical. But before you explore these avenues, ensure that you understand the procedures and processes involved as it can be cumbersome.