Thursday, April 25, 2024

Patients in limbo as doctors clash with medical aid providers

Patients who visit Bokamoso Private Hospital to seek medical assistance are allegedly swindled off large sums of money as it has emerged that they are at times doubled-billed by doctors. It has also emerged that the relationship between medical doctors and medical aid providers is tortured because of alleged failure to uphold professional standards and differences over tariffs.

Documents passed to Sunday Standard paint a picture of a disaster waiting to happen and detail a tortured professional relationship between doctors and medical aid providers as well as cloak and dagger shenanigans at the expense of patients’ lives. The relationship spiraled to an all-time low after a doctor who is based at Mahalapye District Hospital lodged a complaint with Ruben Naidoo, Chief Executive Officer of Bokamoso Private Hospital, over what he perceived as double billing by doctors who provide anesthetic services at the hospital. In an e-mail correspondence between Naidoo and the doctor on 08 May, 2014, when responding to an explanation that Bokamoso does not regulate prices for individual specialists, the doctor said the onus is on all specialists to uphold their professional integrity.

The doctor added that a lady in charge of billing at MediConsultant Group showed him a letter from AFA that also confirmed that medical aid does not cover laryngoscope and intubation, which are basic and integral to giving anesthesia. He also revealed that he has followed the issue up with the claims department at AFA and they confirmed that the practice at Bokamoso amounts to double billing.

“I am aware that AFA have spoken to the anesthetic service providers regarding this issue but they continue to double charge patients. This is unethical. Money and cost recovery are important but they are not above ethics. I don’t mind paying for medical services but it has to be just and ethical, particularly in our field. AFA is aware of this practice. I know that the practice is not regulated yet,” he said.

Responding to Sunday Standard queries this week Naidoo said they have a practice right agreement with doctors and they are not involved in patient-doctor relationship.

“This relationship is a confidential one and we do not intervene. We are not aware of any services that were not rendered and the doctor is in a better position to comment,” he said.

He also confirmed that he received the compliant from the doctor based in Mahalapye and referred the matter to the specialists as the query was about them. While he insisted that his hands were tied as he could not take action against the doctors for their tariffs, Naidoo wrote warning letter on 2 August 2013 to an independent doctor who also provides aesthetic services at Bokamoso.
“It has come to my attention that the billing of fees from yourself are very high for funders. As I do not look at your bills, I suggest you keep the agreed tariff. I’m aware that you also serviced a few patients at no charge as they were out of funds, hence I do not think that your billing is unethical. But I also want you to understand that we work in an environment that is about patient care.”

In an e-mail response to the Mahalapye based doctor’s complaint, Dr Julio Gonzalez of MediConsultants Group said: “AFA only pays for pre-anesthetic consultation (anesthetic time plus procedure code) for any anesthetic services, but they conveniently forget the other well documented modifiers (procedural/clinical) that form part of the anesthesia services.”

He accused AFA of failing to recognize some of the codes used by MediConsultants Group for billing.

“I have not failed to deliver a proper, safe and high quality anesthesia to your wife. It is not me who is failing the patients; it’s not me who wants to ignore safety standards and modern medicine. So think about who is failing you and your wife,” said Dr Gonzalez. He added: “if you consider that the charges for your wife’s operations are too much or unfair, please come and collect a complete refund of the money you paid from our office.”

Dr Gonzalez laid the blame on medical aid providers, especially AFA, as they have caused confusion among patients by failing to disclose to members that there are certain services that are not covered by medical aid.

“We use advanced equipment in performing some of the operations and medical aids do not want to pay for that. For instance we use fibre endoscopic equipment and we have to charge for it. Members of medical aids do not know about this,” he said.

He denied allegations that they bill members for services not rendered. He said there have been cases where they had to perform some operations that they could not deem to be an integral part of the main operation. He said there is lack of knowledge as to what anesthetic operations entail or how they are done.

“Even officers at AFA do not know how anesthetics are billed,” he said.

At one point, Dr Gonzalez and his MediConsultants Group also clashed with another medical aid provider, BOMAID over the medical aid’s failure to pay for anesthesia services and suggested that BOMAID patients should pay a deposit of P5, 000 upfront for anesthesia services. The Group further said the patients will receive itemized invoices after the surgery and later claim back from BOMAID. At the time of going to press, AFA and BOMAID had not responded to questionnaires sent three weeks ago.


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