Medical Bills – do you understand them?

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 received a call from an overwhelmed family member of a Mrs O. Mrs O, a grandmother of 93 years, had recently suffered a fall and a rather expensive emergency operation. The medical aid bill was one they could not afford, plus they found all medical aid communications confusing. 

Mrs O experienced a peri-prosthetic fracture to her hip. The emergency treatment Mrs O received included:

  • Removal and replacement of her current hip prosthesis (due to bone fracturing just below the prosthesis)
  • Both revision hip replacement surgery.

* A prosthesis is extremely expensive, anything upward of R100,000.00.

Not affording to pay the numerous accounts, the family requested Practice Plus to assist with:

  • Liaising with the medical aid
  • Hospital
  • Prosthesis supplier
  • Doctor rooms

Practice PLUS Got to Work:

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

Our team got to work immediately, obtaining a motivational letter from the doctor and liaised with the hospital. We requested Medical Aid to reprocess all accounts and pay in full. Shortly after, the bills got paid in full, except for the prosthesis portion, which limit was reached.

Not stoping our services there; we knew this was not for the patient to pay. With elective joint replacements, a prosthesis limit should not be applied to PMB’s. We challenged the Medical Aid on the prosthesis non-payment response.

Their response:

  • The surgery was a PMB but not an emergency.
  • The procedure took place without authorisation for the prosthesis
  • The prosthesis required during theatre was more than initially quoted to the scheme
  • 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 prosthesis was more than the original quote.

Our final step was to follow up with the hospital and submit the updated claim.

Close on 3-months after starting the process; the total amount got paid.

To Conclude

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

Family Feedback:

Mrs Parker, granddaughter or Mrs O, explains their story: ‘My 93-year-old grandmother broke her hip in September 2019 and underwent hip replacement surgery. We trusted the correct authorisations had been received by all involved. Therefore we were devastated, when in March 2020, we received a notice of rejection from the hospital. The hospital advised the prosthetic hip was not covered by our Medical Aid. 

We contacted Lisa, who then 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 the Medical Aid would cover 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.’

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