There are a number of reasons why a Medical Scheme may not pay your claim, under pay it leaving you with a balance to settle, or pay it from the wrong benefit (for example pay it from your Savings when it should have come from another benefit).
The reasons include, in no particular order:
• Incorrect coding by the doctor’s (or other medical provider’s) rooms
• Incorrect processing by the Medical Scheme
• Scheme rules or benefit structures that prevent the payment from being made.
When your condition is a Prescribed Minimum Benefit (PMB) then, subject to some limitations, the Medical Scheme should be paying your medical bills in full, and they should not be paying it out of your savings account.
As an example of incorrect processing by a Medical Scheme, have a look at the extract from an Ophthalmologist’s statement below:
The Optical Coherent Tomograph for the right eye has been paid by the Scheme, but the one for the left eye has not been paid! This leaves the amount charged for that to be paid by the patient.
Using Med ClaimAssist’s claims engine we can show two things about this claim. Using the codes on the claim we can try to work out what has gone wrong. The first code we analysed was 3028. Our claims engine shows the following information about this code:
Screenshot from output from Med ClaimAssist’s claims engine
This shows that the code can, and should, be claimed per eye. The error is not that a single code should be applied to both eyes.
The code from the claim lines H40.1 is a diagnosis code. The claims engine shows the following for this code:
Screenshot for Code H40.1 from Med ClaimAssist’s claims engine
This shows that the code is for Primary open-angle glaucoma.
The most important thing that the screenshot shows is that the diagnosis is a PMB. This means that the Medical Scheme must pay the claim in full, whether or not the applicable benefit has been depleted.
This is an example of incorrect processing by the Scheme. One of the services offered by Med ClaimAssist is approaching the Scheme administrators on behalf of the patient, and with all the backing facts and information, to get the claim correctly processed and paid.