CLAIM REJECTED DUE TO BAD ADMIN

Good day,

I need some assistance regarding an account from 2019.

Recently I was contacted by Fusion Credit Solutions regarding a summons for me for an outstanding account by Life Glynnwood Hospital in 2019.

Since the date 1/12/2020 I have not heard anything else regarding this matter again and assumed the account issues were resolved, until Fusion Contacted me. Stanford was the person I communicated with but in the meantime does not work there anymore and I believe that from there this case just went cold and no one picked up on what was happening.

After some investigation I found where the problem was. Discovery never received a PMA form and so the hospital claim was never paid which led to me being handed over to Fusion.

I am extremely upset because according to the records I have it all leads back to the trauma doctors and Discovery miscommunicating or rather not communicating at all which now- 3 years later leaves me being threatened with a summons.

Below I have put down all information I have, I have also attached what evidence I have with regards to this account. When I called Discovery again two weeks ago the agent told me that if I can get the doctor to send this form for resubmission it will be paid. It's been a week now and I have not heard back again. He also supp**** me with a letter to send to Glynnwood on what they need and why this claim was rejected.

Since, I have sent it to the trauma doctors and they have also resubmitted the same form AGAIN.

Below I have are dates and information with regards to this claim. From my understanding multiple reference numbers have been used and somehow everything just got mixed up and lost.

I don't believe this is fair for me being issued a summons because the Hospital and Discovery did not communicate with each other effectively that led to this account not being paid. If it were because of an event not covered by the scheme I would understand but this is not the case at all. This is simply just paperwork, a rookie error, that has now escalated into something so much bigger! This claim was not paid due to paperwork that had to be supp**** by the doctors - not because I got admitted for something not covered by the scheme.

28/05/2019

Went to Glynnwood Life Casualties. Dr Pretorius and Hogg (Dr L Vorster) Page 1 of 2 is filled in and signed by Dr L Vorster. (As received by me from Dr Pretorius & Hogg).

29/05/2019

Discovery sends PMA form to Dr Pretorius and Hogg to be filled in for the claim to be processed. (As received by me from Discovery)

03/06/2019

Discovery RESENT PMA form to Dr Pretorius and Hogg for review. (As received by me from Discovery)

08/08/2019

Dr Pretorius and Hogg (Dr L Vorster) fills in PMA section 2,3,4 & 5 on PMA Page 2 of 2. (As received by me from Dr Pretorius & Hogg).

12/09/2019

Dr Hogg & Pretorius submits PMA to Discovery *** (As received by me from Dr Pretorius & Hogg).

***DATE UNKNOWN*** Discovery declines authorisation for Life Glynnwood Hospital account due to ‘no response’ on PMA sent to be reviewed that was sent on 03/06/2019.

30/09/2019

Life Glynnwood Hospital hands over account to Fusion Credit Solutions. (As received by me by Fusion Credit Solutions as per phone call on 07/11/2022)

21/10/2022

I receive summons from Fusion Credit Solutions (first contact from Fusion) for Hospital Bill not paid due to Discovery declining authorisation for hospital event after ‘no response’ on PMA sent for review dated 03/06/2019. (As received by me from Discovery & Fusion Credit Solutions)

31/10/2022

PMA resubmitted again to Discovery by Dr Pretorius & Hogg, reference number *** (***).

“I however see that they’re feedback to you was on the Key care GP to Specialist referral form which Dr. Vorster completed 28/05/2019 with the reference they had and does not seem to have received the attached PMA form as per reference given and sent on the 12/08/2019 by our practice.” – Dr Hogg & Pretorius.

(As received by me from Dr Pretorius & Hogg).

At this point in time I do not know where to go anymore as one person keeps referring the other and trying to get hold of someone at Discovery via phone call took me 3 hours today because either I get cut off, transferred and cut off, no answer. It seems absolutely impossible to get any answers anywhere.

I feel I am at a point where if this does not get sorted out immediately, the claim paid, I will have no other choice but to contact the Council of Medical Schemes and explain this exact situation to them - an account that would have been paid if the paperwork was simply just done and the paper trail simply just followed before handing me over. If someone doing the accounts for both the trauma unit and the hospital simply communicated with each and sent the correct forms using the correct reference numbers at the correct times, there would not have been an issue.

Please assist in resolving this issue as soon as possible.

Warmest Regards

Melissa Luies (nee Strydom)

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