Complaint - Approved Accounts Reversed

Good day,

To whom it may concern:

We have a dispute where our accounts are being approved and then reversed due to back dated and terminated memberships. This is concerning 3 accounts for practices: ********** & ********** .

On time of admission the medical aid released an auth and approved the patient stay for in hospital admission, scheme also confirmed benefits and confirmed patient is active. Although authorization is not a guarantee of payment the scheme still approved the full benefit and yet scheme failed to inform the practice during the course of the patient stay in hospital that the patient is no longer active on the medical aid. Scheme instead updated and approved the patients whole stay in hospital and paid these accounts and only after payment back dated and terminated memberships thus resulted in reversing the practice accounts.

After enquiries and follow up with the scheme regarding this matter the scheme still failed to reprocess these accounts.

The practice unfortunately can't be responsible for this risk as the practice confirmed benefits and validated membership with the scheme. Practice submitted their accounts on approval from the scheme. Surely during the course of approving these admissions the scheme should be able to see a flag and inform the practice of termination.

This is a really big concern to the practice as it seems like it's becoming a continues problem after 3 of our accounts has been reversed due to the scheme that failed to inform the practice of the terminated memberships.

Kindly contact us urgently to resolve these disputes: **********