WHO IS RESPONSIBLE FOR SETTLING THE ANAESTHETIC ACCOUNT?
You, as the patient, are entirely responsible for the account. As a value-added service, we will submit the account to your medical aid upon completion of the anaesthetic, but it remains your responsibility to ensure that the medical insurance company completes the payment and that the account is settled. You have an agreement with the medical aid, and you sign a payment agreement with us before your operation. We do not sign agreements or deal directly with medical aids on your behalf. Often Medical aids will pay us directly, but sometimes they pay patients instead and you are then responsible for paying that money to us. Please note that refusal to do so constitutes fraud.
If there is a shortfall on your reimbursement and you would like to submit the invoice to your Gap cover, we will provide you with the detailed invoices required, but you are responsible for making a timeous submission.
How is my anaesthetic account calculated?
Your anaesthetic account is calculated in accordance with the South African Society of Anaesthetists (SASA) Private Practice Coding Guidelines. The following is a summary to clarify the various aspects of your account.
The anaesthetic account comprises four parts:
Preoperative Assessment (or Premed)
This is the time spent with you outside the theatre prior to your anaesthetic.
It usually takes place in the ward prior to surgery but it may also take place in the theatre waiting area. If necessary, it may also take place prior to your procedure in the anaesthetic rooms, in order to assess your fitness for surgery.
It involves a full medical and surgical history, an examination, a discussion of the anaesthetic techniques (various blocks and monitoring lines including the associated risks). Any blood tests and special investigations will be done during this time.
This consultation may take anything from a few minutes up to an hour, depending on your physical status and the complexity of the surgery.
Basic Anaesthetic Fee
The nature of the operation determines this fee. For example, spinal surgery involves a greater level of complexity than, say, an abscess drainage.
Anaesthetic Time
The anaesthetic is charged according to the length of the procedure. The various factors influencing the length of the procedure could include things such as patient obesity, extent of the disease process, surgical complications and surgical technique to name a few.
Modifiers
There are various modifiers that may be added to the anaesthetic account. These are either:
Procedures (pain blocks, monitoring lines, pain pumps)
Techniques (deliberate control of blood pressure to improve visualization of the operating field)
Risks (eg morbid obesity, extremes of age, musculoskeletal operations)
Will my anaesthetic account be covered by my Medical Aid?
This depends entirely on your medical aid. Medical aid reimbursements and doctor fees began diverging in 1978. In 2006, the Competition Commission ruled that all medical aids and all doctors needed to set their own rates, abolishing the “medical aid rate”. Since then, all medical aids set their own rates for reimbursement, with pay-outs dependent on the medical aid company as well as the plan/option selected. Many medical insurance companies have chosen to loosely base their reimbursement rate on the National Health Reference Price List (NHRPL) – a fee set by the South African government. It is the rate that the state will pay for services to people who have no medical aid and are injured on duty. It is a fee that, in 2010, a court ordered to be withdrawn as it did not take any account of the actual cost of the services. Nevertheless it remains widely used.
Edington and Partners have set our billing rate in line with the South African Medical Association (SAMA) fee schedule of 2006, adjusted with inflation to the present day. It is a rate which better takes into account the cost of running a practice as well as the high level of education and expertise of our partners.
While patients on higher paying medial aid plans may have their account covered by the medical aid, patients on the lowest paying medical insurance plans may have less than a third of the invoice reimbursed.
Please look carefully at the wording of your medical aid contract. When it states that the medical insurance company will pay 100% of their own rate, it is the same as your car insurance company saying they will pay 100% of the amount that they will pay. It is a meaningless statement and it bears no relation to the price of a replacement car.
Is your practice contracted into my medical aid?
Dr’s Edington & Partners have signed an agreement with GEMS and with several arthroplasty (joint replacement) payment schemes. We have not signed contracts with any other medical aid.
I have Gap Cover. Will this cover my shortfall?
Typically, Gap covers are designed to cover the entire shortfall not paid by the medical aid. Most cover fees well in excess of the rate charged by Edington and Partners. However, newer products have come onto the market recently which call themselves Gap cover but which are not designed to actually cover the entire shortfall (most prominently the Gap cover product offered by a prominent medical aid). It is important to know what reimbursement rate your Gap cover will offer.
It is advisable to contact our rooms prior to your surgical procedure in order to get a detailed quote. We will be able to advise you on what portion of the anaesthetic account will be covered, and what the potential shortfall may be.
My quote that I received differed from my final account. Why can I not receive an exact quote?
There are many factors that determine the cost of your anaesthetic. Our rooms and your anaesthetist will attempt to give a rough estimate depending on the type of surgery, however, your final account may vary from that estimate, depending on the various factors stipulated above. Sometimes the procedure may be shorter than expected. Other times it may take longer, or the anaesthetic may be more complicated, in which case the anaesthetist may have had to alter his anaesthetic technique and insert extra monitoring drips.
Does the hospital or the surgeon pay the anaesthetist?
No. We will only accept payments from either you as the patient, your guarantor, or from a medical aid registered with the Council of Medical Schemes. We do not accept payment from hospitals, other doctors, insurance companies or any other third party acting on behalf of the patient.
My case was of such an urgent nature that the surgeon squeezed me in between his elective cases. I received an account with an emergency code despite being done in office hours.
Additional modifiers for emergency/unscheduled surgery may be applied as this increases the risks and skills required to perform the anaesthetic. These codes are applicable whether the emergency case is done in or out of normal working hours.
Why did I receive a separate ICU account from the Anaesthetist?
Post-operative admission to the Intensive Care or High Care Units requires further anaesthetic care and management. This includes ventilation, pain management, haemodynamic and fluid management etc.
There are various ICU categories and modifiers, and they will be added to your account.
I had a procedure but was only given some sedation. I have now received an account from the anaesthetist.
Some procedures are done under light sedation where the anaesthetist administers various drugs intravenously in order to allow the surgeon to perform the procedure. Although the patient is not under a general anaesthetic, the anaesthetist is still present in order to monitor your vital signs and titrate the sedative drugs.
I was only given local anaesthetic during the procedure. I was told that the ANaESTHETIST was only on standby.
Once again, the anaesthetist was still present during the procedure. Despite not giving anything, he/she had to monitor your vital signs, and be prepared to intervene by performing a general anaesthetic. Your payment is for your anaesthetist’s time spent monitoring you and for the expertise at knowing when and how to intervene.
When do I need to settle the account?
Your full account is strictly payable before 30 days. Any account not paid by 60 days will be handed to a lawyer for debt recovery. Interest plus any legal fees will be added.