Meet The Robin Hood Of Medical Scheme Rip-Offs: Clawing Back Big Sums – For A Modest Fee

An entrepreneur has come up with a clever way to tackle the beast of medical scheme rip-offs. Instead of joining the throng of service providers who are squeezing private scheme members for ever greater sums, this Robin Hood of the healthcare sector has identified a way to claw back thousands of rands – for a modest fee.

Independent journalist Ed Herbst, who has an unwavering instinct to uncover news at every opportunity, discovered this enterprise while chatting to a neighbour. The details of this service are too important not to share, he reckons, highlighting how tens of thousands of rands are being directed back to their rightful owners. In a nutshell, the doctor who has started this service has made it his business to cut through complexities and legal nuances and has exposed questionable practices in the process. He can do it for less than R400, all in, and has saved people from bad credit records and cut the additional stress that comes with trying to find unexpected cash sums as a family member struggles with illness. Herbst hasn’t yet found the catch. – Jackie Cameron

As we sink deeper into recession, as the ‘Public Protector’ suggests that the constitution be changed and as we are sledgehammered by one Gupta email revelation after another, good news stories seem to be as elusive as unicorns – but I think I have found one.

A fellow resident in the retirement home where I live told me that her son, a GP, now worked full time for a company that he had started, a company which, for an all-inclusive charge of R399 helps people who feel they are not being fairly treated by the medical aid schemes to which they are contracted.

I thus found myself conversing with Dr David Green and trying to discern, as reporters tend to do, where the catch was.

“So if you save somebody, say R20 000, which their medical aid scheme eventually pays – what percentage do you take?” I asked.

“Just the flat fee of R349 plus VAT”, he replied.

Puzzled, I asked if this augmented his income as a doctor and he replied that he worked full time on this endeavour and business was increasing all the time.

What was serendipitous was that several large medical aid companies in Cape Town had retrenched staff and their skills had proved invaluable in getting his company off the ground.

I asked him to tell his story because, as a pensioner, my sense is that paying R399 to sort out a seemingly intractable problem and potentially saving thousands of rands in the process, must be a worthwhile investment. Ed Herbst

Anne, the wife of Johannes, a Nelspruit security guard wife, was admitted to the local private hospital late in 2016 with an inflamed gall bladder. She was acutely ill – this was a life threatening emergency. After being seen in casualty the surgeon was called and she was taken directly to theatre to have the gall bladder removed – a lifesaving procedure. She was discharged four days later and returned safely to her young family.

Johannes works at a local shopping mall and, as a result of his union membership, he is on a medical aid scheme. He accordingly believed that all the bills relating to his wife’s emergency operation would be covered. The hospital bill was paid in full. However, the medical aid paid both the surgeon and the anaesthetist less than they invoiced. The total shortfall on the accounts was more than R16 000. Johannes was only vaguely aware that there was money still owing to the doctors but when he received invoices from the doctors for the outstanding balances, he assumed that the medical aid would get it right in the end. When a letter of demand arrived from one of the doctors, he set about getting help.

Anne’s diagnosis was Cholecystitis – this is a Prescribed Minimum Benefit (PMB) condition and the medical aid is required, by law with some provisos, to pay for the treatment of this condition in full. Even more so in the event of an emergency which overrides almost all of the provisos which allow medical aids not to pay in full in non-emergencies.

Johannes didn’t know that this sort of thing could happen and had no idea how to resolve his problem. He certainly didn’t have the R16 000 needed to settle the bills. He tapped his concerns into a Google search on his phone and came across an ad for the service provided by Med ClaimAssist. He contacted them through their website and they set about helping him.

Dr David Green, the founder of Med ClaimAssist, (MCA) says that all aspects of deciding how (or if) a medical aid will pay for a claim are extremely complex and leave all but the most informed members confused, and often out of pocket when they need not be. Complex benefit structures and a large variety of rules and exclusions with differences between medical aids and options within medical aids complicate the picture. Leaving the large amount of variety and complex structures aside, medical aids should pay for a set of conditions (PMB conditions) in full and at cost, provided that the treatment is appropriate for the condition.

Many medical aids require that their members go to contracted service providers (known as Designated Service Providers – DSPs) and are not required to pay in full if a member voluntarily chooses not to use a DSP. The use of a non-DSP in an emergency is not voluntary and the medical aid should pay for PMB claims in emergencies.

MCA evaluated Johannes’ claim. “It was a slam dunk”, says Green. “This was both a PMB and an emergency. The treatment was spot on for the diagnosis. There is no way that the medical aid should not have paid the claims in full”. MCA contacted the doctors and asked them to hold off on the collection of the outstanding amounts while they dealt with the problem. Armed with Johannes’ consent they approached the medical aid who requested a copy of the pathology report on Anne’s gallbladder and a written motivation from the doctor relating to the emergency nature of the procedure. MCA got these and submitted them to the medical aid. The claim was then reassessed and paid in full.

Johannes paid R399 (including VAT) for the full MCA service.

MCA provides this service to various corporate clients and direct to the public. They interact with both sides of the tussle – sometime doctors have not coded their claims correctly, MCA calls these doctors to find out where the problem is, and if codes should be dropped from the invoice or changed to clinically appropriate codes. On the other side, medical aids make errors, or do not have sufficient documentation submitted with the claim and tend to err on the side of non-payment. MCA either persuades the medical aid to fix their error, or sources the required documentation.

MCA has worked on thousands of claims and it has become obvious that there are systemic concerns that need addressing. “Some doctors increase their charges when they see that the condition is a PMB, or when the patient has gap cover insurance” says Green. “This puzzles me: surely a doctor should set their fee for the services provided and not inflate the fee based on the insurance that the patient carries?”

On the other hand, many medical aids are insisting that they will only pay for a few hours of care for stabilisation by a non-DSP doctor in an emergency, before requiring that the patient be transferred to a DSP for the medical aid to continue paying for the costs of care in full. “More often than not this is not clinically appropriate and the patient either lands up out of pocket, or risking having to change doctors and hospitals in the middle of an episode of care”, says Green.

By: Ed Herbst

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