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There are several reasons why a medical aid may pay the member directly and not the doctor. If the member is paid by the scheme, it is their duty as a patient to ensure that the doctor is settled in full. It is important to remember that when you have medical aid, the contract is essentially between you and the scheme – your medical aid has to answer and is obliged to you. The service provider, be it a healthcare professional or hospital, may or may not be contracted into medical aids. This means that they will or will not be paid directly by the scheme but it does not mean that the medical aid has to answer to or has an obligation to the service provider.

We will look at three common reasons why a medical aid paid you the member/patient and not the doctor. Remember the money that you have received from your medical aid is not yours unless your doctor’s bill has been settled. So do not start spending it. Doctors across the country have experienced instances where a patient was paid by the medical aid and then did not pay them. Excuses like the medical aid payment to you has tax implications or that you did not receive the money is used by patients over and over so as not to settle their doctor’s bill. Your doctor can send your bill for debt collection and you can even end up with a bad credit record for ‘stiffing’ your doctor on payment.

Doctor Charged Higher Rates

Medical aids pay according to the National Reference Health Price List (NHRPL). The tariffs set out in this list has been agreed upon by several parties. Some medical aids may pay slightly lower rates thereby restricting the doctors and hospitals in their network of providers. If your doctor charges a rate that is higher than NHRPL, the medical aid may then pay you directly instead of the doctor. However, you will only be paid the NHRPL rate. Any shortfall has to be made up for by gap cover or from your own pocket. Some plans pay up to 300% of NHRPL for hospital care and may or may not pay the doctor directly if the claimed amount it higher than NHRPL.

SOLUTION:  You have to settle the doctor as well as any shortfall from what your medical aid paid you and what your doctor charged. It is your doctor’s right to charge a rate that he/she wishes to. If you cannot afford it, see another doctor.

Doctor Contracted Out of Medical Aid

Dealing with medical aid claims can be an administrative nightmare for doctors and their staff. No medical professional is obliged to accept medical aid payments. Many do to help ease the financial strain of patients paying cash to the practice and then claiming back from the medical scheme. A doctor who is contracted into medical aid means that they will submit the claim and should be paid directly by the scheme. Doctors who are contracted out of medical aid do not submit claims or receive payments directly from the scheme. It is possible though that a doctor who is contracted into medical aids may still not receive the money from the scheme. Instead it is paid to you, the patient/member.

SOLUTION: You will then have to settle your doctor as soon as possible. Make sure that you clarify with your doctor at the outset if his/her practice is contracted into or out of medical aid.

Medical Aid Error in Payment

Medical aids do make mistakes. And you may have been paid erroneously. Your scheme may have intended to pay your doctor directly but due to some “computer glitch’ or incompetent staff member (who is usually the glitch), you as the patient and member is paid the doctor’s fees. Medicals aids will not usually reverse the payment to you and then process it later to pay the doctor directly. It is an unnecessary administrative process. All you have to do is simply pay your doctor once the money is in your bank account. After all the money that you receive by this error in payment is the doctor’s, not yours.

SOLUTION: Notify your medical aid of their error and pay your doctor as soon as possible. Do not refuse to pay your doctor because of the medical aid’s error. It is not your doctor’s fault that the medical aid made a mistake but you will bear the brunt of an unpaid bill until you settle it quickly.