PRACTICE FEES AND BILLING POLICY 2023

It is important to familiarise yourself with the fees being charged at our practice in order to avoid disappointment and unwanted/unexpected medical bills. We encourage you to contact us if you have any queries regarding your account. Sometimes a simple telephone call will clear any misunderstandings.

Room Consultations:

All room consultations are payable in full at the rooms. No claims for any room consultations will be submitted to the medical aid by the practice. The patient will receive an invoice which can be used to claim back the consultation fee (or part thereof) from the medical aid.

Room Procedures:

All room procedures and consumables will be charged to the medical aid, provided sufficient funds are available. The patient will remain liable should there be insufficient funds or no out-of-hospital benefit.

In-hospital Theatre Procedures:

Our practice does NOT charge the rates that the Department of Health (DOH) has determined for doctors, which is known as the Reference Price List (RPL). RPL values for services are available from the DOH or from the Health Professions Council of South Africa (www.doh.gov.za).

Our practice billing policy rate is 3.0 times the RPL rate and is equal to Discovery Health Classic rates. This is currently seen as an industry standard for orthopaedic surgical procedures in our area.

The practice is, however, contracted to the following Medical Aid providers:

• Bestmed
• Discovery Classic Direct
• Keyhealth
• Netcare

This means that no co-payment is payable on surgical fees for in-hospital theatre cases with these medical aids. (please note that not all medical aid options may be included).

For elective (pre-planned) surgery, the patient will be provided with a written quotation and estimation of co-payment to be expected. This will only be done for patients with medical aids which we are NOT contracted with.

Unscheduled or after hour theatre cases are billed according to the practice tariff (RPL x 3.0).

Prescribed Minimum Benefits (PMB):

Many orthopaedic conditions that require surgery are regarded as PMBs by the ICD 10 code that is assigned to the diagnosis. Your medical aid is obliged to cover your surgical bill in FULL irrespective of the medical aid or plan that you are on. We try our utmost best to claim your entire bill from your medical aid under PMB conditions, but unfortunately, this is not always possible. We urge you to also put pressure on your medical aid in this regard. If, however, your full account is not paid by the medical aid within three months after your surgery date, you will be held liable for the balance of the account.

GAP cover:

GAP cover is additional insurance, not associated with your medical aid, that is aimed at covering expenses that your medical aid does not pay in full. There are many different insurances on the market, and we do not recommend anyone in particular. Our practice does not work directly with your GAP insurer as in the case of medical aids but provides you with an account balance for you to submit it to your insurer. We strongly advise patients who do not already have GAP cover to explore this option as it is a cost-effective way to insure yourself against large unwanted bills.

A certificate of GAP cover membership must be supplied to the accounts department after you received your quotation.

Your medical aid will make payment according to their rates. The short-paid account will be sent to the member. It remains your responsibility to claim from GAP and proof of submission must be sent to accounts@midstreamortho.co.za

The member is responsible to ensure that the claim is paid within 30 days of submission.

Prosthesis costs:

Many orthopaedic procedures make use of prosthetic implants. These medical devices can be extremely expensive. The cost of these implants forms part of your hospital account and not your doctor's account. It is, however, paid out of a subsection of your medical aid called the prosthesis limit. Please make sure that implants used during your surgery do not exceed the prosthesis limit of your medical aid. This is especially important if previous implant-related surgery was done in the same year. Implant quotations are obtainable upon request and are not provided as standard.

Anaesthetist fees:

We make use of the services of Brink and Partners Anaesthetists. Please contact them if you have any queries. www.brink-inc.co.za