Discovery refuse to pay. What to do?

[IMHO]

Claim for Lancet Laboratories

I have reviewed the claim dated 14th October 2011.

According to the billing rules, the laboratory is allowed to bill for code 4076 up to a quantity of 6 times. According to our records, the practice had billed for the code 4076 for a total of 8 times therefore the 2 codes have been rejected. You are not liable for the amount.

Should the practice wish to confirm this, the practice can contact our Health Partners division on 0860 44 55 66 in order to confirm the billing rules.

This billing is from a laboratory, Lancet, who claim they own the machine and have the right to bill for its use. Now, Lancet is threatening me with ITC and Discovery refuse to pay, saying I do not have to either. It was in hospital and I agree with Lancet, but Discovery has said their final piece and now I am in the middle. The amount is trivial, under R400, but it is the principle of it. Discovery is getting away with murder and also refused to pay some medicine that were used on the grounds that it is not registered. I feel I can blow my top and reported the drugs that was not paid to the Medical Scheme authorities, but not this as yet. In any case, it does not help any to report them as an individual. I pay an arm and a leg for the best plan at Discovery, but must still pay for some services myself. I feel Discovery is taking small amounts from everyone, which ends up being a huge amount of money at the end of the day and they do it because they know they can get away with it.

Lancet on the other hand is ignoring what Discovery is saying in that I do not have to pay. They insist that I must pay and gave me a final warning. So they are also defenseless against Discovery and is not interested in taking on the big guy. Much easier to nail the small guy. Bloody sissies!

What would you do?

[Nickolai Naydenov]

Lancet or any other company for that matter unfortunately can charge as much as they want and we can't change that. What plan are you on, do you have a gap cover, what did discovery pay for that code and what did lancet charge?
I'm registered with the counsil for medical schemes and I deal with med aid besides investments, retirement and etc so I'll be ableto give you an answer once I get your reply

[IMHO]

"counsel for medical schemes" - That is where I send my other complaint about Section 21 drugs not paid by Discovery. (Not registered, but it has a Nappy Code and the Dr. motivated and has given documentation that he has permission from the Medical Counsel.)

CLASSIC COMPREHENSIVE

I were over the gap already.

Lancet did 8 tests. Discovery paid 6 in full. Refusing to pay R363.40 for the other 2 tests @ R181.70 per test. Nothing about the gap, purely the number of tests.

My fight is with Discovery. All In-Hospital expenses is supposed to be covered. It is not as if I lie there, counting tests! And my Dr. will not ask for tests if it is not needed. I had a blood oxygen deficiency and where given extra oxygen to rectify.

Lancet's mail.
"Should medical aid not settle the member is liable for payment." So convenient! Why not fight the medical aid who states I do not have to pay and that I am not liable?

Good day
Thank you for your e-mail.

Please be advised that the blood gas is actually not a test where Lancet takes blood from you. It is in fact a small hand held machine that monitors various levels in the body. Lancet owns the machine and we charge for the use of the machine in hospital. Your Dr would have requested for the hospital nurses to administer the use of the machine to monitor your levels periodically at given times. The machine is used to monitor levels such as oxygen, glucose and other levels depending on the patients condition. Kindly note that this is the amount of times the Dr requested for these levels to be monitored. Should medical aid not settle the member is liable for payment.

Results are printed off the machine once in use, like a pressure machine.

Kind regards

[Nickolai Naydenov]

Ok, sorry I understood it wrong the first time. So they did tests in hospital, discovery is supposed to pay that, what is their reason for refusing to pay? The issue is not with lancet but with discovery! They keep on cutting their benefits every year and increasing their premiums. The only sort of good product discovery had was their medical aid but even that is becoming worse and worse every year. They pay their stuff very well but at the cost of the clients of course, with all due respect it's one company I will never work for no matter the money.

Gap cover I'm talking about covers you up to 400% in hospital not out-of hospital self payment gap!

That medication that you talking about is it a chronic medication? There is a list of conditions that fall part of minimum prescribed benefits and any medical aid must pay for them, however if they are not on that list they won't necesseraly pay for it and instead it will be paid out of your savings.

[IMHO]

I think you still do not understand.

Discovery is saying they only have to pay up to 6 tests and that Lancet has done 8. Discovery further says I am not liable for the account, as Lancet knows they are only allowed 6. So, if I am not liable, who is going to convince Lancet of that, as they surely is not listening to me! From my point of view, Discovery must pay. They authorized the procedure as all in-hospital expenses paid. No monetary limits and no number of tests limit. Discovery is not saying I must pay it myself or that it must be paid from some other account. In-hospital has nothing to do with your savings or chronic benefits. Even my in-hospital chronic medication is paid for under "in-hospital", while I am in hospital.

So, the point is, Discovery is putting a limit on certain tests, which is ridiculous, then continues to say I am also not liable as per these "rules".

The section 21 drugs is not chronic. I had a heart by-pass and the Dr. (anesthetic) used it to ensure my blood does not clog during the procedure and then another one which is the anti-dote to return my blood to normal afterwards. So it was once off administered in theater.

[Nickolai Naydenov]

As I said Discovery must pay for it without a doubt.

Chronic is paid by PMB.

You say the tests were authorized which means they must pay, also when something needs to be done they can't limit you because your life depends on that and as you said in-hospital cover is unlimited.

The medication that was administered to youin hospital should also be paid from your risk (in-hospital) beneit.

Tell discovery that if they don't pay you'll take them to the ombudsman, if still the same take the case to:

Medical aid ombudsman
Hatfield, Pretoria, Gauteng
Hadefield Office Park, Block E, 1267 Pretorius Street, Hatfield
Private Bag X34, Hatfield, 0028, South Africa
Phone: +27 (0)861 123 267
Fax: +27 (0)12 431 0608
Email: complaints@medicalschemes.com
Website: http://www.medicalschemes.com

[Dave A]

So, the point is, Discovery is putting a limit on certain tests, which is ridiculous, then continues to say I am also not liable as per these "rules".

I'd ask Discovery to substantiate their allegation with documentary proof - excerpts of the relevant contracts or medical practice standards which they've drawn from to come to their conclusion.

Put up the proof or pay up.