A claim can be rejected or short-paid for many reasons, but most of them are preventable, and most start before the patient even sits down. Here are the seven we see most often.
1. Wrong membership number or dependant code
One wrong digit and the claim comes back. Copy details from the card at every visit rather than relying on what is already in the system.
2. Expired cards and exhausted benefits
If cover has lapsed, the bill falls to the patient, and it is much harder to collect after treatment. Check before, not after.
3. No pre-authorisation
Procedures, scans and admissions often need authorisation first. Keep a simple list at reception of what needs it for each medical aid, and record the authorisation number on the claim.
4. Missing or wrong codes
Tariff and diagnosis codes decide what is paid. A quick code check before submission prevents the most common short payments.
5. Submitting late
Claims batched up for weeks risk missing deadlines and delay your cash. Submit daily or weekly.
6. Never reading the remittance
If no one matches each remittance to the claims it pays, short payments and rejections simply disappear. A weekly reconciliation turns them into a to-do list.
7. Not explaining shortfalls to patients
Patients who are told about a likely shortfall before treatment pay far more readily than those who receive a surprise bill weeks later.