In terms of Section 59(2) of the Medical Schemes Act, the scheme should pay a claim either to the member or practitioner within 30 days of receiving the claim. According to Regulation 6 of the Medical Schemes Act Regulations, if a medical scheme is of the opinion that an account, statement or claim is erroneous or unacceptable for payment, it must inform both the member and the relevant health care provider within 30 days after receipt of such account, statement or claim that it is erroneous or unacceptable for payment and state the reasons for such an opinion and the member or health practitioner has sixty days to correct and resubmit such account or statement.
Where the medical scheme has failed to either notify the member or health care provider within 30 days that an account/statement/claim is erroneous or unacceptable for payment or fails to provide an opportunity for correction and resubmission, the medical schemes bears the onus of proving that such account/statement/claim is in fact erroneous or unacceptable for payment when there is a dispute.
Practitioners are advised to report medical schemes who unlawfully withhold claims due to them to the Council for Medical Schemes.
Council acknowledges that the guidance provided here is not exhaustive and practitioners are advised to approach Council for further advice by directing an e-mail to Professionalpractice@hpcsa.co.za for guidance on ethico-legal matters.
Council commits to a turnaround time of 10 working days to respond to any request for advice and/or guidance through the e-mail provided above.