Frustrating non-payment of PMBs

Some years ago I travelled around South Africa and visited members of Medical Schemes who were weekly paid workers and members of a trade union. I came across a number of people who, as members of a Medical Scheme, had been hospitalised (or more commonly a family member had been hospitalised) and, when it came to time for the Scheme to settle the bill, there was a significant shortfall in the payment of the hospital and/or the doctors involved. There was a handful of cases where the Scheme member had a judgement against them and had garnishee orders on the weekly wages to pay off this debt.

In those cases where I could get more details, many appeared, on the face of it, to be Prescribed Minimum Benefit (PMB) conditions or emergency admissions to hospital. This suggests that the Scheme may have been required to pay the full costs of the episode and did not do so. What was going wrong?

There are three broad categories of mistakes leading to either the short payment or non-payment of PMB conditions:

• Firstly there are errors on the patient’s side – for example, the 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, then the Scheme will short-pay or not pay the bill.
• Secondly, the provider may have made an error, most commonly submitting an inaccurate or incomplete diagnosis code on the claim to the Medical Scheme.
• Finally, the Scheme could have made an error in processing the claim

Whatever the cause of the non-payment problem, it is deeply frustrating to members of Schemes, and can hurt them financially. Many of the rules, benefits, and codes are complex. Trying to understand them is not easy, and working out where the error is can prove to be well nigh impossible for the average Medical Scheme member.

With this in mind, GreenWest Knowledge Consultants have launched a service to assist members of Schemes to get their claims paid properly. Med ClaimAssist evaluates claims submitted to it by patients through its proprietary Claims Engine to determine how the Scheme should have paid the claim. With this done, it is able to advise members on how to access benefits and/or intervene with either the provider or the Scheme to get the claim properly coded and paid.

The Claims Engine is built on the extensive knowledge and experience of claims processing, Medical Scheme rules and processes, coding, clinical knowledge, and common errors in the industry. It provides a unique, accurate, and rapid mechanism for evaluating claims and determining how they should be paid.