Medical Aid Motivations
What is a medical aid motivation?
It's a standard procedure for medical aids to reject a claim, particularly if it lacks evidence. However, a medical doctor plays a crucial role in reversing this decision. By providing a letter with valid reasons for the treatment, the doctor can effectively advocate for the patient's rights and ensure the claim is paid.
Is medical aid obligated by law to cover the cost of medical conditions?
Yes, it’s a term known as Prescribed Minimum Benefits (PMB) that was incorporated into the Medical Schemes Act. This was introduced to ensure all beneficiaries receive care for certain conditions and do not run out of benefits, in which case, they will be forced to receive treatment at state hospitals. As a result, prescribed minimum benefits cover a range of medical conditions, covering close to 270 health conditions, including menopausal management, types of cancer, meningitis, cardiac management and other medical emergencies. However, limitations may apply in each case, including certain treatment standards and the use of a designated service provider.
A medical aid can refuse to pay for treatment based on the following:
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- The treatment is described as non-essential, in which case, it's deemed not necessarily beneficial and does not impact an individual's overall health and lifespan.
- The medical expenses are related to a previous underlying condition, and the waiting period has not ended.
What recourse should a medical aid member take?
Refusal to grant the desired benefits may be considered unfair, in which case, the beneficiary should take the desired recourse action, which involves visiting the doctor responsible for the diagnosis and treatment of the condition. This way, the medical aid can overturn their decision and decide to cover the cost of treatment should the doctor provide valid reasons for the procedure or treatment. These reasons could include the necessity of the treatment for the patient's health, the lack of alternative treatments, or the urgency of the condition. As a result, the doctor substantiates the decision for treatment and offers valid motivational points in a letter, which is submitted to the scheme for the medical panel to review the motivations for treatment.
How can Complete Billing Solutions assist with medical aid motivations?
Our team at Complete Billing Solutions works tirelessly to formulate a well-written medical aid motivation that specifies the crucial need for treatment. We ensure all the necessary medical evidence is included in the submission, strengthening your case and providing you with the security you need.
FAQ
services
- Registration with Medical Aids and Hospitals
- Patient Data Capturing
- Diagnosis and Procedural Coding
- Claim Submission – Electronic and Manual Submissions
- Payment Follow-Up
- Recovery of Outstanding Amounts
- Reconciliation of Remittances and Private/Gap Cover Accounts
- Monthly-end Reports / Schedules
- Medical Aid Motivations
- Injuries on Duty (IOD)
- SANDF and RMA Billing
Why Choose Us?
With years of experience in the industry, our dedicated team ensures accuracy, efficiency, and professionalism in every aspect of our service. Trust us to streamline your billing processes, allowing you to optimise your practice and improve cash flow. By choosing Complete Billing Solutions, you can expect increased service revenues, reduced cost overheads, stabilised cash flows, more time for patient care, and access to a professional accounts enquiry help desk.