Bonitas Member Magazine Issue 1. 2020 | Page 24

Why won’t my medical aid pay? We are often criticised by members on social media for claims that weren’t paid. There are, however, two sides to every story and the problem doesn’t always lie with the medical scheme. There are a variety of reasons for non-payment, ranging from members not following the correct claiming procedures or rules, to benefits being depleted or even providers not billing correctly. In the following article we’d like to share some tips on what might have gone wrong and how to fix it. Your membership number This may sound simple but it is surprising how often an incorrect membership number or dependant code is submitted with a claim. In some instances, this information is omitted or incomplete. A medical scheme cannot pay without proof that you had the treatment. Remember to update your details if you have changed your medical aid option or medical scheme. ICD-10 codes ICD-10 codes are used by medical schemes and healthcare providers, including doctors and specialists, to identify specific conditions. These must be correct as they are a diagnosis for specific conditions. If there is no ICD-10 code or, for some reason that condition is not covered by your medical aid, the account won’t be paid. Schemes also have sub-limits, for example they agree to pay for rehabilitation and the amount they will cover is finite, so check prior to the treatment. Certain dental procedures have definite sub-limits so it is important to read the fine print and check your policy for what is covered and what is not. Your contributions are not up-to-date It sounds simple but check that your debit order has gone through or that your employer has paid your contribution, as non-payment of premiums could result in your bill not being paid, especially if your membership is suspended. The claim has expired Be aware that there is a cut-off date for submitting a claim. It is usually four months from the date of treatment. Ensure that the correct date is on the top of the account. Page 23 Your benefits are depleted If you do not manage your medical aid benefits carefully you can run out of benefits before the end of the year. This means that you may have to pay the bill yourself. Different options have different limits for various procedures so, once again, make sure you understand what your option covers. Medical schemes are required to pay for Prescribed Minimum Benefits (PMBs) in full, but you may have to use a specific provider. Waiting periods may apply When you join a new scheme there is a waiting period of three months and sometimes, based on your medical history, a twelve month exclusion could be enforced for certain conditions. If you claim before the waiting period is up, the bill will not be paid. Your hospital/doctor is not on the network Most schemes have hospital and doctor networks who agree on certain rates for their members. If you choose to go to another hospital or a private doctor you could end up paying a large portion of the bill. You didn’t use a Designated Service Provider A Designated Service Provider (DSP) is a specific provider that has been appointed by a medical scheme for a specific service. If you choose not to use a Designated Service Provider, you may have to pay a co-payment or not be covered – depending on the Scheme Rules or your specific plan limits. Pre-authorisation was not obtained If you are going to undergo a procedure you need to get authorisation from your medical aid ahead of going to hospital and, once again, make sure you have the right information and ICD-10 codes for this. You’re using medicine that’s not on the formulary Every scheme has a formulary, which lists chronic medication approved by your medical aid. These are often generics which are copies of the original medication but more affordable. Ask your pharmacist for a generic as it will ensure your benefits last longer. The procedure or treatment may be an exclusion All medical schemes have a list of exclusions which are not covered. This often includes cosmetic surgeries and non-medical expenses. If you read the small print and know exactly what the rules are for your medical aid and the plan you are on, you will be able to ensure that your benefits last as long as possible and that the bills are paid.