Case Study 1- Bewildered family faced with costly medical bills

Practice PLUS was contacted by an overwhelmed family whose grandmother, of 93 years, had recently suffered a fall and a rather expensive emergency operation. The family were unable to pay all the bills and were bewildered with the medical aid billing communications.
Case Study 1

How many of us actually understand our medical bills?

Practice PLUS was contacted by an overwhelmed family whose grandmother, of 93 years, had recently suffered a fall and a rather expensive emergency operation. The family were unable to pay all the bills and were bewildered with the medical aid billing communications.

Mrs Oldreive, the said grandmother, experienced a peri-prosthetic fracture to her hip. The emergency operation included removal and replacement of her current hip prosthesis, due to bone fracturing just below the prosthesis. Both revision hip replacement surgery and prosthesis used, are extremely expensive, anything upward of R100,000.00.

The family members who were not in a position to pay the numerous accounts contacted Practice Plus to assist in liaising with the medical aid, hospital, prosthesis supplier and doctors rooms. 

How Practice PLUS Got to Work:

Practice Plus gained permission from the family and immediately noted Mrs Oldreive had undergone an emergency operation which is known as a Prescribed Minimum Benefit (PMB), meaning the Medical Aid is liable to pay for all the accounts in full. 

Our team got to work immediately, obtaining a motivational letter from the doctor and liaised with the hospital. The Medical Aid was asked to reprocess all accounts and pay in full. Soon after the accounts were paid in full, except the prosthesis portion, due to the prosthesis limit being reached. We did not stop our services here, we knew this was not for the patient to pay. With elective joint replacements, a prosthesis limit is used, however should not be applied to PMB’s. We challenged the Medical Aid on the prosthesis non-payment response, which they subsequently advised that the surgery was a PMB but not an emergency; that the procedure took place without authorisation for the prosthesis; that the scheme was not informed that the prosthesis required during theatre was more than initially quoted and that they were awaiting a discount from the prosthesis supplier.

Our staff chased the supplier for the credit note and requested a re-invoice, which they duly did.  We motivated why the procedure was an emergency and why the cost of the prosthesis was more than originally quoted.  Our final step was to follow up with the hospital to submit the updated claim.

Close on 3 months, after starting the process the full amount had been paid; a victory for Practice Plus.

Practice Plus saved the Oldreive family upward of R200 000.00, a year of unnecessary confusion and dread regarding payments they were required to make.

Mrs Oldreive Family Feedback:

 “My 93-year-old grandmother broke her hip in September 2019 and underwent hip replacement surgery. We trusted that the correct authorisation had been received, however, in March 2020 we received a notice of rejection from the hospital to say that the prosthetic hip was not covered by the medical aid. This was devastating for my family as my grandmother is a pensioner and could not pay this amount. We contacted Lisa and she spent the following 3 months in contact with the surgeon, medical aid, prosthetic supplier and medical aid. She never gave up, constantly reassuring us. In July 2020 we received notice to say that the medical aid would now be covering this cost. I don’t know how Lisa did it but I do know for a fact that we couldn’t have done it without her. She saved our family a lot of money and stress, and we are immensely grateful. We could not recommend her services more highly.”  Mrs J Parker, Granddaughter.

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