When medical aids don’t pay a claim in full it can really hurt financially and is very frustrating for the member. The rules and regulations, benefit design, and hoops that the medical aid asks the member to through are confusing at the best of times.
Sometimes the non-payment by the medical aid is for a Prescribed Minimum Benefit (PMB) condition which the medical aid should pay in full. What goes wrong with these payments?
There are three broad categories of challenges leading to either the short payment or non-payment of PMB conditions:
- Firstly there could be errors on the patient’s side – for example, the medical aid 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 medical aid 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 aid.
- Finally, the medical aid could have made an error in processing the claim
MedClaim Assist specialises in identifying where the problem lies and helping to sort it out.
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