Surprise medical bills for Medical Aid members: What you need to know

Surprise medical bills for Medical Aid members: What you need to know

Statistically, 1 in 5 emergency-room admissions result in a surprise out-of-network bill. In this article we explore the topic of ‘surprise medical bills’ and ‘balance billing’ and how this impacts South Africans, even if they have a medical aid or hospital plan. By the end you will have a much clearer understanding of the financial risks you face along with solutions on how to deal with them.

A Texas man is recovering from two heart attacks – one of the medical variety, and the other of the financial variety, after receiving a whopper $109 000 (R1,544,088) bill for his hospital visit. Unsurprisingly, as a result, in the last few weeks ‘surprise medical bills’ and ‘balance billing’ as a topic have come under fire internationally.    

While you might not be planning to go to Texas anytime soon; or the emergency room for that matter, this topic is one you should be concerned with as a South African trying to go about your business of living and making ends meet in a tough economy.

You may, just like most, feel comfortable with your medical aid or hospital plan and that you are protected from the potential financial stress of any sudden in-hospital medical needs. However, a recent dispute between health companies internationally, has made it clear that “balance billing’ is a concept that is alive and well (even in South Africa) and the consequences of it need to be fully communicated and understood.

What is balance billing?

At the heart of the dispute is so-called “balance billing”.  Balance billing happens after you’ve paid any co-payment and your medical scheme has also paid everything it’s obligated to pay toward your medical bill. Any balance owed on that bill for any doctors or hospital expenses becomes due by you. You’re being “balance billed”. The discrepancy between what a physician or hospital charges for a service and what the medical scheme covers can leave consumers unknowingly on the hook for tens of thousands of [Rands] if, for example, they visited an in-network facility but received care from out-of-network doctor – like an anesthesiologist.” A medical bill like this could blindside you and drastically disrupt your financial stability.

According to examples provided by the South African Medical Association (SAMA), where:

  1. “a doctor submits an account of R500 for his consultation fee to the patient and the patient’s Scheme. The doctor keeps both the patient and their Scheme in the loop by ensuring there is transparency in the request for payment to be made. The account may specify the amount that the Scheme must pay and the amount that the patient must pay”, and
  2. “a surgeon submits his claim to the patient’s medical scheme for R12 000, and the assistant also sends a percentage on the whole amount (R12 000) to the medical scheme”, this is considered as balance billing and is allowed (legally).

Why balance billing spells risk for South Africans

When receiving a bill for an in-hospital stay there is no way you can predict what the total amount might be that you must pay in. Also, in an emergency, you may be allocated a doctor or specialist that is ‘on duty’ and does not have a network agreement with your medical scheme. Since your medical scheme hasn’t negotiated any rates with that provider, he or she isn’t bound by a contract. It is a known fact that medical practitioners can charge up to 500% more than what your medical scheme option is willing to pay. That means a huge chunk of your doctor’s bill needing to be paid out of your own pocket. These “surprise” balance billing situations are particularly infuriating for patients, who often believe that as long as they’ve selected an in-network medical facility, all of their care will be covered under the in-network terms of their medical scheme option.

You can protect yourself from balance billing

With ‘balance billing’ being dragged under the public microscope, we begin to realise just how often these gaps in medical cover occur. It is therefore natural for consumers to feel quite helpless. While this is a real threat, fortunately there is an affordable options and steps that South African consumers can take to avoid being caught in the balanced billing trap.

What can you do?

You may have heard of gap cover before, but perhaps you haven’t really understood its purpose. In short, Gap Cover is a medical insurance that you take out over and above your medical aid so that these unforeseen and unpredictable balance billing shortfalls are covered. At a very low cost of only R171 for your whole family, you can be protected from the gap between what the doctors charge you while in hospital and what your medical scheme pays out. Here are some examples of common medical procedures, with associated, combined charges of the specialist and anesthetist. The third column illustrates the payment shortfall an individual on a standard, 100% of MSR (medical scheme rate), scheme option would experience. An individual with GapCover® won’t have to pay for this shortfall themselves.

ProcedureAmount charged by practitionerPotential shortfall incurred (Payable by GapCover*)
ColonoscopyR14 509.82R4 805.82
Back FusionR105 301.95R68 188.31
Shoulder OperationR19 081.86R11 958.34
Joint ReplacementR46 660.48R23 597.41

These are just a few examples of the many different treatments and operations covered by GapCover®.

GapCover® is an affordable solution that tops up your medical scheme shortfalls on in-hospital expenses. Visit for more information. Balance billing is no problem when you have GapCover®.

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