Hospital Rip-Off

[SauRoNZA]

When last did you do a course? I did one 3 years ago and one of the only change is the number of compressions to breaths. Ambu-bags are still used as well AFAIK. That never changed. CPR = chest compression and artificial ventilation. The one major change I noticed was to deal with major blood loss before breathing.

End of last year.

See above link.

 

[lkswan747]

mi - myocardial infarction is a pmb condition, classified as a medical emergency.
a medical emergency involving a pmb condition allows a patient to be treated at any hospital until stable, dsp or not. medical aid is legally obliged to pay in full.
patient can only be transferred to another hospital once stable and confirmation of available bed at receiving hospital has been received be the transferring hospital. if no bed is available at dsp, patient has to be kept at original hospital - medical aid has to continue payment until such time as a bed has been secured at the dsp facility.

account submitted to medical aid must have icd-10 codes + tariff codes. these can only be supplied by the hospital / treating doctor

resuscitation fee
most hospitals (private) have an emergency dept with resuscitation room.
the emergency dept is run by a private practice using the hospital's infrastructure
(doctors are not allowed to be direct employees of the hospital group)
the resuscitation fee could comprise fees from the private practice that runs the er, + hospital facility fees + radiology (most resuscitation rooms have radiology equipment), + pharmacy fees.
resuscitation (cardiac or respiratory) is carried out only in emergencies - again, a pmb condition. medical aid is obliged to pay in full.
you friend must request an itemized invoice on the resuscitation fee

**paying in full means payment at full medical aid tariff
more often than not actual tariffs are higher than medical aid tariffs - hence co-payments.

if he has problems with medical aid regards the payments, pm me

Thanks will advise once he receives the revised statement from the medical aid. Greatly appreciated.

 

[Grant]

Medical aid to recoup R100m claimed 'fraudulently' by private hospital and doctors

The Government Employees Medical Scheme claims it lost R100m to scores of private doctors and hospitals between 2012 and 2019.

www.iol.co.za

the entire healthcare system is fukked - from top to bottom.
the opaque billing system between medical schemes and hospitals is bizarre.
the lack of transparency is breathtaking.
double billing
billing for in-hospital services never rendered


and here's a big fat can of ugly worms waiting to be opened - the costs medical schemes unwittingly absorb as a result of fixing medical errors & negligence caused by hospitals.

 

[Kosmik]

I've questioned a number of hospital bills over the years, to the benefit of the medical aid. Gap have also raised issues with the medical aid. The joke is, you as the laymen should not be doing the arguing or stuck in the middle, that is the medical aid job.

During a medication issue I was once told by A Discovery consultant that it was my issue to adhere to their policies, I very quickly jacked them up as the provider was one of their own dsp's not external and it was their job to police their agreements not mine.

 

[lkswan747]

I've questioned a number of hospital bills over the years, to the benefit of the medical aid. Gap have also raised issues with the medical aid. The joke is, you as the laymen should not be doing the arguing or stuck in the middle, that is the medical aid job.

During a medication issue I was once told by A Discovery consultant that it was my issue to adhere to their policies, I very quickly jacked them up as the provider was one of their own dsp's not external and it was their job to police their agreements not mine.

I find that the medical aid seems to place the onus on the patient to get the correct information whenever the medical aid has an issue with payment. I do not know how the process works except that I get a statement from the medical aid detailing what they will pay and reaon code for why they have not paid a certain item. Now my question is:
Does the reason get communicated to the medical service provider as to why the medical aid is not paying or does the patient need to do the necessary follow-up without the service provider knowing why they have been short paid?
Surely it should be the medical aid responsibility to follow up with the service provider should they require any further clinical or other information regarding the submitted claim.

 

[Grant]

He received his statement from the medical aid which had declined payment due to the fact that the account submitted by the hospital had insufficient information for them to consider payment.

i'm going to take you a step back

statement arrives - statement will have a code at the end of the billing line item
that code will indicate non payment is for "x" reason.
in this case, the code "x" indicates insufficient information.

so now, has the medical aid company paid nothing, or have they paid out of "day to day" / savings / etc
to clarify: resuscitation (for example) would be paid out of "major medical", not out of "day to day" / savings etc.

where i'm really going with this is, if the hospital has received R0 - let them sort their schit out with the medical scheme. the medical scheme would have paid if the hospital provided the required info.
its not for the patient to supply icd-10 codes, nappi codes & tariff codes.

if the hospital has been paid, but out of your friends "day to day" benefits - chase them down.


netcare resuscitation fee 2019:


i've replied to your pm.
if this by chance is related to netcare, i'd be delighted to take them on