NETCARE CLAIMING MORE THAN AGREED WITH DISCOVERY

Dear Netcare Kuilsriver Accounts Department,

I am writing in connection with the recent SMS I received from Netcare Kuilsriver, which reads as follows:

“Netcare Kuils River Hospital Ref ***: Medical aid short payment. Please settle R6,225.61. Contact ***.”

This message refers to an alleged short payment relating to my recent admission at your facility. Kindly take note of the attached summary from Discovery Health, which provides full details of all claims submitted by Netcare Kuilsriver in respect of this admission.

According to Discovery, the shortfall of R6,225.61 is not due to any failure on their part to pay but because Netcare billed amounts exceeding the Discovery–Netcare agreed tariff. Discovery Health has already settled the claims in full at the rates agreed upon between Discovery and Netcare.

Below is a summary of the claims in question: Procedure Claimed Amount Paid by Discovery Shortfall 1 R2,807.60 R2,358.40 R449.20 2 R12,388.20 R10,406.10 R1,982.10 3 R2,064.70 R1,734.35 R330.35 4 R13,218.00 R11,106.00 R2,112.00 5 R6,194.10 R5,203.05 R991.05 6 R631.40 R530.40 R101.00 Total — — R5956.70

As stipulated in Section 59 of the Medical Schemes Act 131 of 1998, medical schemes are required to pay contracted service providers directly at the agreed rate. Furthermore, where such a contract exists, the service provider may not recover any additional amounts from the medical scheme member beyond those contracted tariffs.

It follows, therefore, that any attempt to recover the above “shortfall” from me is inconsistent with this provision. Discovery has fulfilled its payment obligations, and I am not liable for the additional amounts charged by the hospital above the agreed tariff.

The only amount I remain liable for in respect of this admission is R259.91, relating to medication not covered by Discovery Health.

I therefore formally request that: 1. This invoice and the corresponding SMS notice be reviewed and reversed; and 2. Written confirmation be provided that no outstanding balance remains payable other than the R259.91 mentioned above.

Should this matter not be resolved promptly, I will have no choice but to escalate the issue to Discovery Health and the Council for Medical Schemes (CMS) for formal investigation.

Please confirm receipt of this correspondence and the attached Discovery payment summary.