FEDHEALTH IS A BULLY

This complaint is being written on behalf of a medical practice that has been trying to get hold of Fedhealth Medical Scheme, but with no luck.

When a person joins a certain Medical Scheme, there is a contract between said person and said Medical Scheme to settle accounts on behalf of the person(s) on the Medical Scheme with contracted Health Care Providers.

This is the following scenario that happened with our practice:

The patient visited our practice in February 2021 for a service to be rendered. We confirmed the benefits with The Schemes administrator (there was enough funds available in the savings account to be able to settle the claim in full). The funds were released from a vault. There is a separate agreement between a member and the Medical Scheme where the funds are released upon request of the member and is then paid back to the Medical Scheme over a specified period of time. The service was rendered, the patient collected the product and payment was received from The Scheme's Administrator all within the same month. We closed off the account on our side as there was nothing more to do on the account.

Fast forward 6 months later, we received a letter from the Administrator stating that we need to pay back the settled amount to them. We queried the reason and were informed that they are not allowed to give us a reason and we should just refund them. We tried numerous times through the Administrator to get a reason from them as to why, as well as trying to get hold of the member and The Medical Aid Scheme, but with no luck.

A month later, we received a 2nd letter stating that the funds are to be paid back within a week, or we will be handed over to a lawyer for collection of the money. We once again tried to get hold of The Medical Scheme but no luck. We tried going though to the number that was given to us, but it just reverts back to the Administrator who cannot help us. We eventually spoke to a supervisor at the Administrator, who informed us that they do not have jurisdiction and just do what they are told by The Medical Scheme. We told them that there is no way that we will just pay back a large amount of money without a reason. He then gave in and said that the patient / member has been suspended in May 2021 already.

Thus, in summary, the member broke his/ her contract with The Medical Scheme. They now expect us to pay back the amount for a valid claim, where there was funds available and the patient was active at the time of the claim. We met all requirements for the claim to be valid from the Practice's side.

If it happened that we as a practice submitted a claim late (after 3 months of service date), the claim would have been rejected due to being a stale claim, yet the Medical Scheme has "the right" to demand from us to pay back funds AFTER 6 MONTHS.

We also tried contacting the CRM for assistance but according to them they cannot assist us as we have not done enough from our side. This after we have tried contacting all parties involved ( including the member / patient) numerous times but met a dead end every time.

The Administrator has now off- ended the amount from other claims that has been submitted. Therefore, accounts of other members are showing that they have not been settled in full.

We consider this to be a very unfair situation where we are bul**** into paying funds back to The Medical Scheme where we have met all the requirements for a valid claim and was paid by them (therefore there is an admission that the claim was valid). The onus should be on the member to pay the funds back to The Medical Scheme as the contract was between the Member and the Scheme. THAT contact was broken and should not have effected the Service Provider, as the claim was valid and we have also paid OUR providers for the products.

Compare the following scenario with ours:

A client takes out a bank loan in order to purchase a car from a dealership. The deal goes through, the client receives his car, the dealership receives their money from the bank. The client then decides not to pay his loan back to the bank. Now the bank expects the dealership to pay back the loan to them whilst the client is still enjoying the luxury of his vehicle. Sounds great right? Just a pity that this is NOT the case and will NEVER happen! The client will always be responsible for the repayment due to the contract that was signed. Why is this now different because we are not dealing with a bank but with a Medical Scheme?

We as a Service Provider are at the point of saying that should a patient come to us and they are on Fedhealth Medical Scheme, that we would unfortunately not be able to assist them unless they pay for the service themselves and claim back from the Scheme as we cannot risk submitting claims and then the money is lost because the Scheme claims money back as it pleases them.