MED CLAIM ASSIST FAQ

1What % of claims are legitimate claims?

An excellent question! Roughly a third of the claims that come to us are "valid" in that we expect to have some benefit to the client either by getting the scheme to pay, or by clearing up a coding issue with the doctor. However, of all the 23 584 claims dealt with to date, we have only had two clients who have not been happy with our service. The two thirds where we cannot get the scheme to pay (or the doctor to fix a bill) we work with the patient to explain why, and how they might better access services in future. Our clients are uniformly happy with this, and view it as a valuable part of the service.

2Once a member has submitted all information for claims what are the turnaround times offered to client?

Our average turnaround time is 6 working days. This is often dependant on scheme response times

3Example of current reporting and how frequently the organization receives reporting

We report monthly: Number of claims processed by us, Total Rand Value of claims processed, savings achieved by getting the scheme to pay, savings achieved by doctor intervention, total savings, and average turnaround time in days. This is all in an Excel spreadsheet, and each month shows the full history of the client on our system.

4Trends of where current shortfalls are occurring

The big numbers are in surgery and confinements. A patient admitted for emergency surgery is very likely to have a shortfall that should not be there!

5Statistical information over past three years on number of claims and pay out of claims

Since April 2017 we have processed 22 928 claims (we have a number before that, but prior to that the data is incomplete). In that time we have saved our clients R37,146,288.63, split roughly two thirds as scheme pay outs and one third as doctor originating savings.

6Average pay out of claims

The average pay out on successful claims is about R5,000.00 per claim

7Current clients utilizing the Med claim assist product

Our clients include Admed, Ambledown, Stratum, Medway, Kaelo, and Zestlife, as well as general members who approach us directly. We have working relationships with all doctors, and all medical schemes