Practitioners must be aware that it is unethical to charge lesser fees for patients paying out of pocket and higher fees for patients covered by medical insurance.
The Health Professions Council of South Africa (HPCSA) has recently been inundated with complaints from the public relating to out of pocket payments even when they are covered by medical insurance.
Patients who opt to pay out of pocket for services rendered by practitioners do so because practitioners charge a lesser fee for patients paying out of pocket and a higher fee for patients covered by medical insurance. The HPCSA has also noted that practitioners are reluctant to provide patients who pay out of pocket with account statements. Having noted the above, the HPCSA wishes to guide practitioners on the following legislative framework:
1. Section 53(2) of the Health Professions Act States that: “Any practitioner who in respect of any professional services rendered by him or her claims payment from any person (in this section referred to as the patient) shall, subject to the provisions of the Medical Schemes Act, furnish the patient with a detailed account within a reasonable period”.
2. Section 59(1) of the Medical Schemes Act states as follows: “A supplier of a service who has rendered any service to a member or to a dependant of such a member in terms of which an account has been rendered shall, notwithstanding the provisions of any other law, furnish to the member concerned an account or statement reflecting such particulars as may be prescribed”.
3. Section 59(2) of the Medical Schemes Act states that, “a medical scheme shall, in the case where an account has been rendered, subject to the provisions of this Act and the rules of the medical scheme concerned, pay to a member or a supplier of service, any benefit owing to that member or supplier of service within 30 days after the day on which the claim in respect of such benefit.
From the above legislative framework, practitioners are advised as follows:
a. Practitioners should charge the same fees for similar services rendered irrespective of how the patient is going to settle the account. It is unethical to charge lesser fees for patients paying out of pocket and higher fees for patients covered by medical insurance.
b. It is within the rights of patients to use out of pocket payment method even when they are covered by medical insurance and such patients should be provided with a detailed account for services rendered.
c. Where patients opt to use out of pocket payment method for services rendered, it is unethical for practitioners to submit claims to the patient’s medical insurance for the same services.
Practitioners are advised to exercise due diligence in this matter, especially with their administrators or accountants.
Last Updated on 7 August 2015 by HPCSA Corporate Affairs