There can be no doubt that the administration of the claims of one ambulance private ambulance service by a competing private ambulance is potentially anti-competitive.
However, in the absence of intervention by authorities such as the Competition Commission, how does an ambulance service manage the blatant non-compliance with the Medical Schemes Act by a number of medical schemes and certain assistance companies that represent them?
Do you as an ambulance service owner consider it to be acceptable to constantly have to resubmit claims that were correctly submitted the first time around, and to constantly motivate for full payment of claims where the patient treatment that was provided was done so ethically and correctly?
The answer in short, is that these matters should not be the responsibility of the ambulance service owner. Should a patient choose medical scheme cover that does not ensure that the payment of claims to providers is being managed efficiently and effectively, then the ambulance service provider must pass the responsibility for the payment of these claims back to the patient in question.
Effective cash flow management is essential to the sustainability and development of your ambulance service. As a business owner, you need to be aware that you have already entered the private ambulance service industry with the disadvantage of having to wait up to 30 days for the payment of claims, whereas business owners in other sectors work on a cash up-front, or payment within 7 working days principle. To wait any longer than 30 days for payment of claims is simply unacceptable, and a financial risk to both your business and the ongoing employment of your staff.
SAPAESA is suggesting that the only approach to medical scheme claims in going forward should be the following:
- Submit your claim directly to the medical scheme concerned.
- At the same time, submit a copy of the claim to the patient, with a covering letter stating that the payment of the claim remains the ultimate responsibility of the patient. SAPAESA suggests that the following phrase should be included: “This account has been submitted to your medical scheme for payment as a courtesy, however please note that full settlement of this claim remains your own responsibility. Please follow up with your medical scheme to ensure that they have received this claim and are processing it for payment. Payment is due no later than 30 days from the date of submission.”
- If the claim is not paid promptly by the medical scheme in question within 30 days, for whatever reason, submit the claim to the patient for payment with immediate effect. Explain to the patient in a covering letter that payment has not been settled correctly within 30 days by their medical scheme. Explain to the patient that payment must be settled in full within 14 days. Failure to settle the account in full will result in patients being handed over to legal representatives for debt collection – a process that may even include blacklisting.
- If the claim is not settled by the patient within the allocated 14 days, then the invoice must be handed over to a professional and effective debt collection agency for further legal action.
While we realise that some ambulance services are reluctant to take such aggressive measures to ensure that claims are paid, medical schemes have unfortunately left the majority of the market with very little further choice. It is time for private ambulance services to stand up to medical schemes that pay very little attention to the poor administration of their claims. Demand payment and do not back down until you achieve it. Sadly, very little rectification will be made in this regard until private ambulance services become more proactive about the management of cash flow and the settlement of outstanding debt.
If you do not currently have an efficient debt collection agency assisting you with your claims, then SAPAESA recommends that you consider making use of the services of Hammond Pole. More information can be found at the Hammond Pole website www.hammondpole.co.za and queries can be addressed to CharlmagneB@hammondpole.co.za.