Why won’t my medical aid pay?

It’s a lament we often hear. Why won’t my medical aid pay?

There are, however, two sides to every story and the problem doesn’t always lie with the medical scheme. There are a variety of reasons for non-payment. These range from members not following the correct claiming procedures or rules to depleted benefits. Or even providers not billing correctly.

Gerhard Van Emmenis, Principal Officer of Bonitas Medical Fund, offers tips on what went wrong and how to fix it.

The important thing to remember is that medical aid scheme options differ. That means some options cover procedures that others might not. However, there are certain rules everyone needs to adhere to. Your medical scheme will usually tell you the reason for non-payment. If you are unhappy you can take it up with them, however, the best advice is to first check that the fault doesn’t lie with you or the medical practitioner.

Why won’t my medical aid pay – Your membership number

This may sound simple but it is surprising how often an incorrect membership number or dependant why won't my medical aid paycode is submitted with a claim. In some instances, claimants leave out this information or it is incomplete. A medical scheme cannot pay without proof that you had the treatment. Remember to update your details if you have changed your medical aid option or medical scheme.

Why won’t my medical aid pay – ICD-10 codes

Medical schemes use ICD-10 codes and healthcare providers, including doctors and specialists to identify specific conditions. These must be correct as they are a diagnosis for specific conditions. If there is no ICD-10 code or, for some reason your medical aid does not cover that condition, the medical scheme will not pay the account. 

Schemes also have sub-limits, for example they agree to pay for rehabilitation and the amount they will cover is finite, so check prior to the treatment. Certain dental procedures have definite sub-limits so it is important to read the fine print and check your policy for what it covers and what it does not cover.

Why won’t my medical aid pay – Your contributions are not up to date

It sounds simple but check that your debit order has gone through or that your employer has paid your contribution. Non-payment of premiums could result in an unpaid bill – especially if the medical aid has suspended your membership.

Why won’t my medical aid pay – The claim has expired

Be aware that there is a cut-off date for submitting a claim.  It is usually four months from the date of treatment. Ensure that the correct date is on the top of the account.  

Why won’t my medical aid pay – Your benefits are depleted

If you do not manage your medical aid benefits carefully you can run out of benefits before the end of the year.  This means that you may have to pay the bill yourself. Different options have different limits for various procedures so, once again, make sure you understand what your option covers. By law medical schemes have to pay for Prescribed Minimum Benefits in full but you may have to use a specific provider. 

Why won’t my medical aid pay – Waiting periods may apply

When you join a new scheme there is a waiting period of three months and sometimes, based on your medical history, a twelve month exclusion could be enforced for certain conditions.  If you claim before the waiting period is up, the bill will not be paid. 

Why won’t my medical aid pay – Your hospital/doctor is not on the network 

Most schemes have hospital and doctors networks who agree on certain rates for their members. If you choose to go to another hospital or a private doctor you could end up paying a large portion of the bill.

Why won’t my medical aid pay – You didn’t use a Designated Service Providers

A Designated Service Provider is a specific provider that has been appointed by a medical scheme for a specific service. If you choose not to use a Designated Service Provider, you may have to pay a co-payment or not be covered – depending on the Scheme Rules or your specific plan limits.

Why won’t my medical aid pay – Pre-authorisation was not obtained

If you are going to undergo a procedure you need to get authorisation from your medical aid ahead of going to hospital and, once again, make sure you have the right information and ICD-10 Codes for this.

Why won’t my medical aid pay – You’re using medicine that’s not on the formulary

Every scheme has a formulary, which lists chronic medication approved by your medical aid. These are often generics which are copies of the original medication but more affordable. Ask your pharmacist for a generic as a matter of course as it will ensure your benefits last longer.

Why won’t my medical aid pay – The procedure or treatment may be an exclusion

All medical schemes have a list of exclusions which are not covered. This often includes cosmetic surgeries and non-medical expenses.

Van Emmenis says, ‘If you read the small print and know exactly what the rules are for your medical aid and the plan you are on, you will be able to ensure that your benefits last as long as possible and that the bills are paid.’

Bonitas is the second largest open medical scheme in South Africa. Administered by Medscheme Holdings (Pty) Ltd, Bonitas aims to make quality healthcare accessible to all South Africans and offers a wide range of plans that are simple to understand and easy to use. The Fund has the largest GP network in South Africa, a Specialist Network and a host of supplementary benefits paid from risk and carefully crafted managed care programmes to cover chronic conditions, cancer, diabetes and HIV/AIDS. This allows members to derive real value for money and stretch their benefits as far as possible.

All info was correct at time of publishing