In South Africa we have the 3rd best level of medical service in the private sector throughout the world. This is a privilege and not necessarily a right. The payment for this privilege is often referred to as “grudge Tax” and as distasteful as it is to include the topic on a practitioners website, I thought it necessary.
The subject of money is always and emotional one, and patients do not know whether they are coming or going with respect to their medical aid policies (Often the brokers or employers fault). These policies are insurance for health just like any other type of insurance and we as healthcare providers have no control over which policy a patient decides upon. However, because we are the ‘Face’ in the system, as clinicians we often bear the brunt of the discontent from patients and insurers alike. This is despite the fact that our fees at most form only 25% of the total cost per in- hospital event.
Generally all we want to be are clinicians, not businessmen.
As a rule I do not discuss or haggle over the details of the fee amounts with my patients. This is the function of my personal assistant and the practice manager. At the beginning of each financial year I set the level at which my practice bills, which is 250% of the basic discovery health rate for that year. (Please refer to billing info on home page). The procedural fees also always includes all follow-up visit fees for 6 months after the surgery. I do not charge for repeat scripts or subsequent correspondence on my patient’s behalf. This is where my involvement with the money ends and is outlined in the patient contract that all patients have to sign before seeing me. Prior to undergoing surgery all patients are given an estimate of my fees, linked to specific diagnostic and procedural codes. With this, patients can check to see exactly what their insurance will pay out and thereby be aware of any shortfall, if any. I advise that everyone obtain GAP cover insurance which is around R200-R300 pm for individuals, and usually covers the shortfalls in specialist fees. GAP cover is provided by the short term insurance companies and now also Discovery I see. Please refer to your broker.
My practice is not a retail outlet and my professional services are at set fees. Legally a medical practice is not a registered financial services provider and therefore we are unable to provide a credit facility, which is what payment later than 30days amounts too. Another fact is that if a clinician charges different rates for the same procedure depending on whether the patient is private, on medical aid, or an emergency etc.; then they can be investigated for unethical billing practice. Everyone is equal in the eyes of the law.
My job is to be a clinician and to do the best I can for my patients. I put the same effort into every one of my patients. As a medical professional, all I have to sell is my time, knowledge and surgical skill. The latter has taken more than 16 years to gain, including the fellowships, and is ongoing. When I was taught to be a doctor, no one told me I would have to run a business , I was trained to be a doctor! This unfortunately can be difficult for all concerned in the private health sector.
When you are booked for surgery you will be given an estimate of my professional fees. On the estimate is a list of all possible procedure codes that may be used during any particular surgery. This is the maximum number of codes applicable to this surgery. Each code has a monetary value. If some of the codes are not used during surgery, these will not be included in the final bill. NB Because a number of the hip Operations I perform are new and highly specialized, there are still no specific codes and therefore we will use equivalent procedure codes as for other joints.
An estimate also contains the diagnostic ICD-10 codes. All of these codes need to be presented to the insurance/ medical aid company for authorization. The authorization number needs to be forwarded to my secretary. The hospital requires this authorization number before admission.
If implants are applicable to the surgery and where practicable,then quotations from the companies which provide the implants will be forwarded to you the patient upon request. The patient is responsible for contacting their medical aid and determining their annual limit with regards to implants/ prostheses. This is essential to determine because there may be a shortfall which you the patient will be liable for. These implants are normally invoiced via the hospital directly to the medical aid. A shortfall however will result in an invoice being sent by the hospital directly to you the patient. If there is going to be a shortfall because your medical aid or insurance policy has a low prosthetic limit, then my secretary will be happy to forward the relevant company representatives details so that you can try negotiate a discount. Again, some GAP cover policies also assist with these shortfalls. By doing this I place responsibility on you the patient for managing your finances and being completely aware of the costs of any surgical procedure in as far as it involves the professional services. The hospital where the surgery takes place will of course bill separately and directly to the medical aids for all their expenses which form the greater part of the bill.
As an independent professional my anaesthetist will deal directly with my patients in respect of their professional fees.
Please remember that 15% of the bill is in fact TAX in the form of VAT.
PMB (Prescribed Minimum Benefit) Legislation
This letter serves to provide you with information regarding the so-called Prescribed Minimum Benefit (PMB) Conditions. Certain medical conditions have been legislated by government as Prescribed Minimum Benefit Conditions that require your Medical Aid to pay out in full all Professional fees, which are usually above medical aid rates, from their Common Risk Pool of Funds. This is independent of your policy details. If your condition is a Prescribed Minimum Benefit Condition, in order to avoid any co-payments from your side, I would strongly advise that you contact your Medical Aid and inform them of the fact that you have a PMB Condition for which they should reimburse all Professional Service Providers involved in full. Most PMB Conditions in orthopaedics, are normally associated with congenital conditions, fractures and infections. This legislation was designed to protect the consumer from out pocket expenses when subjected to unforeseen medical problems. Essentially only elective surgical procedures are covered according to the rules of the medical insurance policy you belong to. (FYI, Carte Blanche has screened an expose on this very subject in November 2010).
Payment in full for these PMB Conditions is dependent on certain provisos and these include the following: That your medical condition is considered a relative emergency and that you have received care in an institution which is a Designated Service Provider (DSP) as defined by your medical aid policy. Failing this, that you under went medical treatment on an involuntary basis in a non-DSP facility due to the emergent nature of your condition. The relevant ICD-10 diagnostic codes will be found on your statement together with the usual letter which we send to the Medical Aids informing them of the fact that your condition is a PMB condition and attached to this is the relevant PMB code which they will usually require. We will also provide you with the medical schemes council contact details should there be any dispute with your medical aid. My fees remain, as per legislation, the standard practice rate which is charged for all conditions, whether they fit in with the PMB codes or not. Some surgeries relate to congenital conditions and are highly specialized and only performed by a few surgeons in the country including myself, wrt hip surgery. If the surgery cannot be performed by any other surgeon in any other hospital, including the state, then if it is a PMB condition the medical has to pay in full. This is often the case with Dysplasia patients needing Peri Acetabular Osteotomies for example, as am one of only a handful of surgeons who can perform this operation.
I strongly advise you to be cognizant of your rights as a patient as it is often the case that medical aids will try and avoid paying in full unless they are taken to task. Please ask my secretary for further details.
I hope that you find this note useful.
Dr. T.W. Munting