This article will assist you in assessing claims, for clients on the Discovery Medical Scheme where the scheme has imposed a penalty co-payment on the provider's account. 


Instructions: 


TABLE OF CONTENTS

Step 1: Identify Providers 

  • Refer to the reason codes on the medical aid statement for the specific admission your are assessing. Read the description of the reason code for the short payment of the claim



Step 2: Make sure all amounts correspond 

  • Make sure that the amounts charged per tariff codes charged for correspond with the latest medical aid statement.

Dr Smit: 



Dr Van Heerden: 



Step 3: Assess the Gap component 

  • Capture the claim in the assessment grid, with the scheme rate as the paid amount, provided that the scheme did pay something towards the tariff code. 


Dr Van Heerden:


Total Charged: R 922.80

Total Paid: R 773.00

Total Shortfall: R 149.80


Dr Smit:


Total Charged: R 6 966.71

Total Paid: R 3483.30

Total Shortfall: R 3 483.41



Step 4: Assess the penalty co-payment

  • Take the total shortfall reflecting on the medical aid statement and subtract the amount assessed under the Gap Component.


Dr Van Heerden:



R 304.40 - R 149.80 = R 154.00 


Therefore R 154.00 will be loaded as a Penalty co-payment for Dr Van Heerden.


Dr Smit: 



R 4 180.07 - R 3 483.41 = R 696.66 


Therefore R 696.66 will be loaded as a Penalty co-payment for Dr Smit.


Step 5: Load the amounts under the correct benefit tiers 


Gap Components loaded: 



Penalty Co-payments loaded:



Things to consider: 
  • The scheme will not pay their scheme rate on the accounts where the scheme has imposed this penalty co-payment
  • It is important to load the amounts under the correct benefit as this will affect the OAL and the client's claims submitted after this claim.