IF YOU are having difficulty in getting a medical scheme claim paid, particularly for a major procedure, or if you believe your scheme under-paid a claim and are facing a doctor’s demand for payment, there is a company to which you can turn for help.

Med ClaimAssist, run by a medical doctor, David Green, will take up your claim with your medical scheme in an effort to ensure that you are reimbursed the amount to which you are entitled.

Green started his operation about 11 months ago after having difficulty in getting his elderly mother’s medical bills paid by her scheme. He says he advertised his service online and was flooded with calls. His company now even assists insurers offering gap cover (insurance that bridges the shortfall between what you pay and what your medical scheme pays if you are hospitalised).

The fee is R399 (including VAT), and this is only if Green takes on your case. He considers each case on its merits. About half of requests are taken up, Green says, and, of these, he has a 80% to 90% success rate in obtaining further reimbursement from the medical scheme.

“You pay a large sum of money to your medical scheme every month,” the Med ClaimAssist website says. “Then, when you do end up claiming for a legitimate medical expense, the scheme either doesn’t pay or part-pays your claim. 

“Sometimes, the reasons for the non-payment are legitimate, and sometimes not. Sometimes the problem lies with the doctor’s rooms (or other service provider) not entering the correct code on the claim to the medical scheme, and sometimes the problem lies with the scheme not processing the claim correctly. Either way, sorting the problem out needs detailed understanding of complex coding systems, rules, and a bit of medical knowledge thrown in.  

“Med ClaimAssist analyses your claims, identifies where the problem lies and approaches the source of the problem (be it the doctor’s rooms or the medical scheme) with all the facts, rules and regulations lined up, and assists you in getting the doctor paid.”

Green says the call centres that deal with claims typically have scripted responses to queries, and consumers are often put off pursuing their claims, because they have neither the tenacity nor the “fair degree” of knowledge required.

If Med ClaimAssist takes on your claim, it requires your consent to deal with both your medical scheme and your doctor, and all the accompanying documentation. The claim, from there on, is in its hands and out of yours.

Green says a big source of under-payment or non-payment is the prescribed minimum benefits (PMBs). These are benefits that all medical schemes are obliged to cover, no matter what plan or option you are on, and relate to about 270 life-threatening conditions, the list of which is available on the website of the Council for Medical Schemes (www.medicalschemes.com).

In an emergency involving a PMB condition, your scheme must cover your treatment in full, no matter which doctor or service provider you use. If it is not an emergency, the scheme may insist that you use one of its designated providers if you want to be reimbursed in full. 

The scheme may not use the funds from your medical savings account, if you have one, to pay for the benefit.

Problems arise if the treatment codes (which indicate whether or not a treatment is for a PMB condition) are incorrect, or the medical scheme is not aware that the event was an emergency. 

If you’re unsure about a particular code (known as an ICD-10 code), Green’s website has a tool that allows you to check whether it is for a PMB condition. Go to http://medclaimassist.co.za/

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