Help me understand PMBs & what's covered

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ros_b

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I'm on Discovery Classic Smart - essentially a network hospital plan (no MSA). Broke my wrist and went to a network emergency room. They did xrays, then a "closed reduction" in the ER, then more xrays. I paid for the xrays and the ER visit. They sent me home with an instruction to go see an orthopedic surgeon who would assess the xrays and advise on further action. Doc advised surgery, got the pre-auth, Discovery paid everything related to the day surgery (I went to a network facility).

Now I've submitted an "Application for out-of-hospital treatment of a PMB" and they're covering the initial xrays and ER bill (they're so incompetent that they incorrectly paid the provider instead of me, even though I provided proof of payment, but that's a separate issue...), but I'm wondering if they should also cover the initial orthopedic surgeon consultation (R1200), since they're supposed to cover "the costs related to the diagnosis, treatment and care of: any emergency medical condition...." And what about post-op physio visits? I'd like to be armed with the correct info if I'm going to have fight with them.
 
ros_b said:
I'm wondering if they should also cover the initial orthopedic surgeon consultation (R1200), since they're supposed to cover "the costs related to the diagnosis, treatment and care of: any emergency medical condition...." And what about post-op physio visits? I'd like to be armed with the correct info if I'm going to have fight with them.
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Yes they should cover a certain amount of physio, for several months, and the initial consult. You might find the doctor charges for the paperwork itself, which will pose an interesting question as to whether it's worthwhile. They hate those smart plans afaict.

Ask though. And if you have no gap cover, tell them once you have their invoices. We got the gap reduced by half (30% discount in total) from anaesthetist and surgeon just like that.
 
Thanks. I don't have gap cover, but I'm not sure where gap cover comes in... the surgery bills have all been covered in full. It's just the out-of-hospital bills that I'm trying to get covered under the PMB rules. I guess the orthopedic surgeon and physios probably charge more than what Discovery's rate is, but I understand I'll have to cover that gap myself - I'd rather get something out of Discovery than nothing for those visits!
 
ros_b said:
Thanks. I don't have gap cover, but I'm not sure where gap cover comes in... the surgery bills have all been covered in full. It's just the out-of-hospital bills that I'm trying to get covered under the PMB rules. I guess the orthopedic surgeon and physios probably charge more than what Discovery's rate is, but I understand I'll have to cover that gap myself - I'd rather get something out of Discovery than nothing for those visits!
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If the in hospital specialists were covered in full you've done well already. Have you got the statement to that effect?

You definitely can get something out of them for physio etc but as I say, the PMB paperwork is intended to be a hassle and the doctor may bill you for it.

Of course, that's not covered.
 
Would appreciate any advice here myself too. Been struggling with Momentum hospital plan being a big pain about PMB (kids broken arm).

Seems the process for the is:
1. Submit claim
2. Reject claim
3. Contact as dispute telling them it is a pmb
4. Support accepts it's a PMB
5. Still don't pay
6. Ask why not paid - repeat from number 1 or 2...

Anyone have any advice on regular or ombudman or something. Even a facilitator who can do the admin for us :) doesn't even matter what if they just pay R20 of the doctors as we have gap cover that will pay us the rest provided momentum pay something!!
 
richjdavies said:
Anyone have any advice on regular or ombudman or something. Even a facilitator who can do the admin for us :) doesn't even matter what if they just pay R20 of the doctors as we have gap cover that will pay us the rest provided momentum pay something!!
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I was reading some older posts, trying to figure this stuff out, and someone mentioned these guys: https://www.medicheck.net.za/.
I can't vouch for them, but it might be worth contacting them to find out more about the service they offer.
 
richjdavies said:
3. Contact as dispute telling them it is a pmb
4. Support accepts it's a PMB
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With Discovery at least there is a step 3.5 where you get a form to fill out to motivate for PMB designation, and it requires input and a signature from the specialist.
 
ros_b said:
I'm on Discovery Classic Smart - essentially a network hospital plan (no MSA). Broke my wrist and went to a network emergency room. They did xrays, then a "closed reduction" in the ER, then more xrays. I paid for the xrays and the ER visit. They sent me home with an instruction to go see an orthopedic surgeon who would assess the xrays and advise on further action. Doc advised surgery, got the pre-auth, Discovery paid everything related to the day surgery (I went to a network facility).

Now I've submitted an "Application for out-of-hospital treatment of a PMB" and they're covering the initial xrays and ER bill (they're so incompetent that they incorrectly paid the provider instead of me, even though I provided proof of payment, but that's a separate issue...), but I'm wondering if they should also cover the initial orthopedic surgeon consultation (R1200), since they're supposed to cover "the costs related to the diagnosis, treatment and care of: any emergency medical condition...." And what about post-op physio visits? I'd like to be armed with the correct info if I'm going to have fight with them.
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They don't generally pay assessments done before and they definitely don't pay anything after, only whatever was done in hospital. For that you need one of they higher plans. Definitely not physio.

Edit: see tomtomtomtomtom's post below.
 
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Tomtomtom said:
If the in hospital specialists were covered in full you've done well already. Have you got the statement to that effect?
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So far it appears that there have been 4 claims associated with the surgery (anaesthesiologist, the facility itself, the surgeon and the radiographer), and only R354.08 of the facility bill appears to have not been paid (partly under reason code "Your healthcare provider may not claim for this item, because it is classified as a non-chargeable item. You do not have to pay this amount." and partly under reason code "We have not paid this amount as this item does not have an item code (NAPPI code) on the claim. Please ask your healthcare provider to include the item code and send the claim to us again".) I was quite surprised since the surgeon told me they charge 215% of Discovery rates and my plan covers up to 200%.

The PMB application stuff is confusing as hell, what with them paying the provider instead of me for some bills, and then I just saw that bill from the Emergency Room doctor's practice has not been paid for reason code "Your health plan does not cover this service". The initial orthopedic surgeon visit has been partially paid at the Scheme rate, but it was paid from my Personal Health Fund, not from the scheme.

Anyway, I'll get it all sorted eventually - luckily I have the time and the patience to hound them.
 
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