Discussion Points

In my opinion, PMB claims are rewarding and cost saving, but you have to be sure about your story because what you may see as PMB case may be argued as NON-PMB and your claim will pay at 100% scheme rate. So, be open minded. Also, if you have a network arrangement, you may not charge more than the agreed rate because of the advantage it has.

Patients with PMB conditions should register their conditions with their funders so they may benefit from PMB Basket and save costs.

Bona fide emergencies are prescribed minimum benefits that require full honouring of payment. The condition has to require immediate treatment in hospital or surgery and if not treated, could either cause:

• serious impairment to a bodily function,
• serious dysfunction of a body part or organ,
• or death.

this situation attract may attract a fee as specified in modifier 0011 and items 0146 or 0147

Annexure A of the Medical Schemes Act provides a long list of conditions identified as Prescribed Minimum Benefits. The list is in the form of Diagnosis and Treatment Pairs (DTPs). A DTP links a specific diagnosis to a treatment and therefore broadly indicates how each of the approximately 270 PMB conditions should be treated. The treatment and care of PMB conditions should be based on healthcare that has proven to work best, taking affordability into consideration.

Specific tariff guidelines have also been set to assist with the billing of the above information. That is where we pay most attention.

Medical Coders read medical records, extract the diagnosis from those records and translate the diagnosis into ICD-10 coding.

Once coded, data can be used in a number of ways. One of them being submission of claims which is called medical billing.

You will be surprised to find out that we are able to get 2018 claims paid so much later after the incident.

We’ve done it over and over again & it works

Our clients are so glad we could help

Why don’t you try us?

If clinically sound, it will be approved, and the approval will benefit everyone whose claims were on hold or rejected.

.. and the bigger the file, the bigger the problem.

In 2019, when we started, I had to prove myself to a prospective client and I am proud to have recovered stale claims worth R 2 468 986.23 combined amount for both our client and the hospital stale claims. Take an investigation project with us.

We’ve recently defended a case of rhabdomyolysis (muscle crush injury). Client faced with a REJECTED hospital bill of R 38 892.12. Drs account also rejected for R4 621.00. In line with PoPi Act, we investigated between the Dr and Hospital. Clinical report submitted with substantial evidence. Within 3 days CASE APPROVED and claim was resubmitted for payment.

You will be surprised how many cases we solve every day. Before you accept a rejection. Check with us.