Medical Procedure Costs and Split Billing
By Rudolph Ackermann, CEO at MANAGE ALL
Source: Council For Medical Schemes And Related Legislation
Split billing by doctors in South Africa refers to a practice where doctors bill patients and their medical schemes separately for the same service, often at different rates.
This practice is considered unethical and potentially illegal as it can lead to patients being billed higher amounts than what the medical scheme covers.
Doctors are legally obligated to disclose the full cost of treatment before services are rendered.
What Is Split Billing?
Split billing involves a doctor providing two accounts for the same service: one for the medical scheme (at the scheme’s tariff rate) and another for the patient for the difference between the scheme rate and the doctor’s actual fee.
Why Is It Unethical And Potentially Illegal?
It violates the principle of transparency and can lead to patients being charged more than they anticipated, creating a discrepancy between what the scheme pays and the amount the patient is billed.
Legal Requirements:
The Health Professions Act requires doctors to disclose the cost of treatment to patients and their medical schemes before services begin.
Consequences For Doctors:
If a doctor is found to be split-billing, they may face disciplinary action, including being reported to the Health Professions Council of South Africa (HPCSA).
Impact On Patients:
Patients may experience higher out-of-pocket expenses than expected, leading to financial strain.
Transparency And Disclosure:
It’s crucial for patients to understand the full cost of treatment upfront and to be aware of the potential for co-payments or out-of-pocket expenses.
Reporting Split Billing:
If a patient suspects split billing, they should inform their Manage All advisor who will assist in reporting the matter to the medical scheme, the BHF (Benefits Health Fund) or the Council for Medical Schemes.
Important Consideration:
One of the most prevalent abuses in the medical space occurs when the cost of medical procedures is inflated because members disclose beforehand that they have Top -up/Gap Cover.
Members should therefore be mindful of the following:
Top-up/Gap Cover is a loose standing re-insurance policy that protects members of having to pay out of pocket for procedures that exceed the limits allowed by their medical aid policies.
An abuse of Top-up/Gap Cover benefits will unavoidably lead to a review of cover benefits and/or contribution increases that affect every policy holder.
There is no need or obligation on a member to disclose details of their Gap Cover to any medical practitioner, and we urge members to refrain from doing so.
