Momentum Health SHAM

<p> </p> <p>Maternity benefits a sham:</p> <p>With my first pregnancy I had severe problems with Momentum and as I knew what the problem was I wanted to jump the gun this time to make sure I don't have the same problem now with my second pregnancy (as I had to repay numerous accounts that were claimed, back to Momentum out of my pocket so that they could fix their mistakes and then only pay me back for the correct scans!) in order for this to be sorted out now - to no avail. My broker had to fight this for weeks to get sorted out - she did the best she could at that stage even though Momentums reasoning was poor. You get to a point of being tired to always have to fight with your medical aid AND GIVE UP.</p> <p>The doctors are prescribed certain codes that they have to use as per their guidelines in terms of scans and ultrasounds. The specified codes are as follows (supp**** by the medical scheme): the costs included are averages that I have found from calling around to different Doctors all of them using the same codes:</p> <p>5107 + z32.1 (singleton) 1 baby – R1550.00</p> <p>z32.1 + 5104 (twin): NT scan (11-13 weeks scan) – R1550.00</p> <p>z36.3 + 5104 (twin): Detail scan (18-24 weeks) – R1450.00</p> <p> </p> <p>3615: Routine Obstetric Ultrasound (this has to be done by the doctor every visit in order to ensure that there are no problems in the womb, placenta, amniotic fluid or abnormalities with the baby/babies. – R385.00</p> <p> </p> <p>According to the medical aid the below codes are all accepted in terms of their benefits schedule for the 2 scans that are paid for by the scheme, however please note the costs difference as well as the definitions of these scans! (same codes as app**** above?)</p> <p>5107 + z32.1 (singleton) 1 baby – R1550.00</p> <p>3615: Routine Obstetric Ultrasound (this has to be done by the doctor every visit in order to ensure that there are no problems in the womb, placenta, amniotic fluid or baby. – R385.00</p> <p>3617: another code that according to 3 different consultants at Momentum is also an accepted code and can be claimed</p> <p>They did not even make mention of code 4104 which is exactly the same as code 5107, but is just indicative of more than 1 baby.</p> <p>Please note definitions below:</p> <p>Routine Obstetric Ultrasound:</p> <p>This type of ultrasound is used during pregnancy. Ultrasound scans are a safe and non-invasive way to examine the foetus. Measurements are taken for the assessment of gestational age, size and growth of the foetus. A full anatomic assessment is made during this exam. This is a non-invasive and safe means of evaluating foetal health, determining gestational age and assessing the intrauterine environment. It is an indispensable tool for the practice of obstetrics. The routine ultrasound examination is a beginning. It is a diagnostic test, yielding results that must be interpreted and integrated in a knowledgeable way. As is true for physical examination, the ultrasound study is most helpful when performed in a consistent and reproducible fashion, carefully documenting the pertinent positive and negative findings that are important in clinical decision making. The information gained from routine obstetric ultrasound may provide reassurance, guide therapy, or identify a pathologic condition that merits further investigation. It is always informative.</p> <p>NT Scan at 11-13 weeks:</p> <p> Nuchal translucency is a collection of fluid under the skin at the back of your baby's neck. It can be measured using ultrasound: between 11 weeks and 13 weeks plus six days of pregnancy or when your baby measures between 45mm (1.8in) and 84mm (3.3in) (NHS 2010) - A nuchal translucency screening, or NT screening, is a routine ultrasound performed between week 11 to week 14. Foetuses with increased fluid at the base of their necks — a spot known as the nuchal fold — may have an extra chromosome. This fluid can be measured with ultrasound when the base of the neck is still transparent. Because the nuchal fold becomes less transparent as your baby grows, timing is crucial. In addition to Down syndrome, NT screens for con******* heart defects and other genetic disorders.</p> <p>Detail scan (very Important)</p> <p>An anomaly scan takes a close look at your baby and your womb (uterus). The person carrying out the scan (sonographer) will check that your baby is developing normally, and she'll look at where the placenta is lying in your uterus.</p> <p>o To reassure you that your baby is likely to be normal</p> <p>o To confirm the gestational age of your pregnancy</p> <p>o To confirm the number of foetuses and, if twins, whether they are identical or not</p> <p>o To detect birth defects, such as a spina bifida or heart problems</p> <p>o If you are concerned about the chances of chromosome problems like Down syndrome, this scan can search for subtle markers that may suggest a higher risk that your baby may have one of these problems</p> <p>o If you want to know your baby's gender this can usually be seen at this scan</p> <p>End Result according to Momentum: attachment: Momentum maternity benefits</p> <p>According to Momentum, they only pay for 2 scans “pregnancy scan” when you ask them which 2 scan these are that they pay for, the answer is as follows from 3 different consultants – Momentum Benefits pay for the 11-13 weeks scan and the 18-24 weeks scan. (when you use the words “NT scan” or “Detail scan” they have no idea what you are talking about, they then call it growth scans. Which you can obviously see from their own stated benefits must be something different to a pregnancy scan as they are differentiating between the 2 in terms in their different scheme plans!</p> <p> </p> <p>On this note – please note from the previous detailed costs mentioned ( and again detailed below), the two scans that they claim they pay for is R1550.00 and R1450.00 respectively (as always without a doubt – I am 100% that MOMENTUM knows what these scans cost! And they do not pay for the Routine Ultrasounds that have to be done at each gynae visit to maintain an understanding of your baby’s health and yours as the mothers which averages R385.00. Yet they find it more important to pay for every Urine Test (dipstick) not even close to the same LEVEL OF IMPORTANCE TO YOU AND YOUR BABY’S HEALTH! (but wait, they actually do pay for it – they allocate the 2 scans to the cheaper Ultrasounds thereby getting out of paying the actual expensive ones that you are actually supposed to be covered for!!!!!)</p> <p>Momentum states that as mentioned above, the following codes will be accepted by Momentum as scan codes for the “ Pregnancy Scans”:</p> <p>3615/7 = R385 Routine Obstetric Ultrasound</p> <p>5107/5104 = R1550 ----- NT scan (11-13 weeks scan) </p> <p>5107/5104 = R1450 ----- Detail scan (18-24 weeks)</p> <p>NB!! Yet in the same breath they tell me that the Routine Obstetric Ultrasounds (which I had to explain to all the consultants that I spoke to as they have no idea what these are!!!!!!!) are not covered by Momentum Health Benefits. Hello do you understand what you have just said????</p> <p>So here is a breakdown of a Pregnancy for you as Momentum that struggles to understand how this works!!!! And their misrepresentation:</p> <p>So at the end of the day MOMENTUM allocates payment to two of the Ultrasounds done during routine visits and then don’t pay for the 2 expensive scans as stated in their benefits or by their consultants over the phone. Ie they pay 2x R385 instead of the R1550 and R1450 leaving the member yet again at huge deficit! Why are we paying these huge amounts for medical aid every month??????</p> <p>“MOMENTUM ends up allocating the 2 scans “pregnancy scans” as per the benefits to the Routine Obstetric Ultrasound instead leaving you as the member with even more unpaid claims!!!!”</p> <p>It is absolutely unacceptable how unprofessional and under qualified the consultants of Momentum Health is. And they are VERY quick to tell you that your DR is the one who is making the mistake not them, yet all the Dr’s that I have contacted refuse to work with Momentum patients by submitting their claims – we have to pay upfront and then try and claim back – because the doctors are aware of the incompetence’s. They also say that they do not have these problems with other medical aids such as Discovery Health!!!! Only Momentum!</p>