Guidance on split-billing

Split-billing occurs when a medical supplier provides two accounts for the same service. One is sent to the medical scheme, listing the medical scheme tariff amount, and another to the member or patient. The member will pay the supplier what they think is a co-payment, but the amount paid does not appear on the claim sent to the medical aid by the supplier. This is unethical practice.

The HPCSA remind health practitioners have an obligation to inform the patient about the cost of services before rendering the services. It should be noted that this has nothing to do with the benefit option the patient has purchased with their medical aid or the scale of benefits of the medical aid in relation to the service to be provided.

Health practitioners also have an obligation to furnish their patients with detailed accounts for the services rendered as prescribed in terms of Regulation 5 of the Medical Schemes Act. The account should include the nature and cost of each relevant health service rendered. Should there be an amount paid by the patient, that same amount should reflect on the account. The same account should be sent to both the patient and the medical scheme for the purpose of reimbursement.

Patients have an obligation to pay for the services rendered to them irrespective of the method of payment, whether through their medical schemes or out of their own pockets. If a medical aid is a method of payment, the Medical Schemes Act places an obligation on the medical scheme to do so within 30 days of receiving the claim.

Split-billing would occur if a patient is billed separately for the amount to be paid by the patient or member which the scheme does not cover, and the medical scheme is billed separately in line with the medical scheme tariff amount. In other words, the account to the patient reflects only the amount for which the patient is responsible, while the claim or account to the medical scheme reflects only the amount equal to the benefits the medical scheme is prepared to pay for the service rendered and does not reflect the out-of-pocket payment by the patient. Split-billing is unethical and practitioners should refrain from such a practice.