LD
Lesego D
1 reviews | Active since Jun 2024
18 Jun 2024, 10:37
Unpaid bills - horrible service!
My mother's first knee replacement was done in Aug 2022 - the surgeon and hospital were fully paid by Sizwe Hosmed. A year later, she had her second knee replacement in Nov 2023 with a different surgeon since the first one didn't go too well. Both surgeries were authorised by medical with the same codes, yet last year's one has been partially paid and my mother now sits with a large bill, on top of many copayments. Many back and forths with Sizwe Hosmed have left us with nothing but many reference numbers. How can one surgery be fully paid for then a year later it is partially paid? Each consultant gives a different excuse from escalation to a backlog in paying bills to there's nothing wrong with the claim which is absolutely ridiculous. How can no one provide answer and actually resolve the matter? The customer service is terrible!
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Replies (3)0
Replies (3)
Sizwe Hosmed Medical Scheme's replyOfficial
18 Jun 2024, 10:55 Dear Lesego,
Thank you for submitting your query and apologies for the inconvenience caused.
Thank you for the provided reference numbers, we will investigate and escalate the query for urgent attention.
We appreciate your patience.
Sizwe Hosmed team.
Thank you for submitting your query and apologies for the inconvenience caused.
Thank you for the provided reference numbers, we will investigate and escalate the query for urgent attention.
We appreciate your patience.
Sizwe Hosmed team.
Sizwe Hosmed Medical Scheme's reply18 Jun 2024, 10:55
Official
Dear Lesego,
Thank you for submitting your query and apologies for the inconvenience caused.
Thank you for the provided reference numbers, we will investigate and escalate the query for urgent attention.
We appreciate your patience.
Sizwe Hosmed team.
Thank you for submitting your query and apologies for the inconvenience caused.
Thank you for the provided reference numbers, we will investigate and escalate the query for urgent attention.
We appreciate your patience.
Sizwe Hosmed team.
Sizwe Hosmed Medical Scheme's replyOfficial
18 Jun 2024, 12:44The claim was paid at scheme rates.
The query is closed.
The query is closed.
Sizwe Hosmed Medical Scheme's reply18 Jun 2024, 12:44
Official
The claim was paid at scheme rates.
The query is closed.
The query is closed.
LD
Lesego D's updateReviewer Update
18 Jun 2024, 20:10According to your team, both claims were paid at scheme rates, though one was paid in full and the other was partially paid. In both instances, the service providers were above scheme rates. The one surgeon put the claim through the hospital as a "fixed fee" whereas the other submitted their claim individually as a "fee for service". Fixed fee payments are supposed to be for private paying patients. Sizwe Hosmed authorised a provider that is above scheme rate to bill in such a way that they were fully remunerated, even above scheme rates. Now, you cannot provide us with a benefit guide or scheme rules that shows this is ethical and/or allowed. It is not the patient's responsibility to enquire the technicalities of the service provider's billing, it is only their responsibility to accept liability for any shortfalls, which we did in both instances. No patient is a medical billing expert. Again, you cannot provide us with any guidance or rules that state that not only liability but also billing rules fall on the patient. Now, when we are sitting with a massive shortfall, you want to claim scheme rates. If that is the case, we should have had a shortfall in 2022 as well.
Thank you for confirming that Sizwe Hosmed can and will change their "rules" on how bills are processed as there is no finite guidance you can provide. We will escalate the matter further until we get full clarity on the correct way to process billing from a service provider who is above scheme rates.
Thank you for confirming that Sizwe Hosmed can and will change their "rules" on how bills are processed as there is no finite guidance you can provide. We will escalate the matter further until we get full clarity on the correct way to process billing from a service provider who is above scheme rates.
LD
Lesego D's update18 Jun 2024, 20:10
Reviewer Update
According to your team, both claims were paid at scheme rates, though one was paid in full and the other was partially paid. In both instances, the service providers were above scheme rates. The one surgeon put the claim through the hospital as a "fixed fee" whereas the other submitted their claim individually as a "fee for service". Fixed fee payments are supposed to be for private paying patients. Sizwe Hosmed authorised a provider that is above scheme rate to bill in such a way that they were fully remunerated, even above scheme rates. Now, you cannot provide us with a benefit guide or scheme rules that shows this is ethical and/or allowed. It is not the patient's responsibility to enquire the technicalities of the service provider's billing, it is only their responsibility to accept liability for any shortfalls, which we did in both instances. No patient is a medical billing expert. Again, you cannot provide us with any guidance or rules that state that not only liability but also billing rules fall on the patient. Now, when we are sitting with a massive shortfall, you want to claim scheme rates. If that is the case, we should have had a shortfall in 2022 as well.
Thank you for confirming that Sizwe Hosmed can and will change their "rules" on how bills are processed as there is no finite guidance you can provide. We will escalate the matter further until we get full clarity on the correct way to process billing from a service provider who is above scheme rates.
Thank you for confirming that Sizwe Hosmed can and will change their "rules" on how bills are processed as there is no finite guidance you can provide. We will escalate the matter further until we get full clarity on the correct way to process billing from a service provider who is above scheme rates.