Author Topic: MME Rates, PPR Rates and what the doctors charge  (Read 3015 times)

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Offline Dalene Steenkamp (Coetzee)

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MME Rates, PPR Rates and what the doctors charge
« on: August 01, 2011, 04:24:08 PM »
Everyone on a medical aid fund (specially in SA & NAM) knows what I am talking about when I say MME and PPR rates.

What bothers me is the blatand disregard for these rates that some doctors and specialists have.  A local GP in Kathu charges twice the MME rate for a consultation (where mostly you go to him after having diagnosed yourself with an ailment and only asks for a prescript).  Some specialists specialise in doubeling up fees on PPR rates.

Effect of all this is that your medical aid fund does not cover the costs in full, or else the costs are covered from your day-to-day limits, meaning that before the benefit year is out your funds are depleted and you have to incur all costs from your own pocket.

A short story to accompany this statement:  I am getting quite fed up with doctors charging what they want and service not being rendered propperly for those astronomical amounts.  Thus I have taken on 2 docs from the last hospital round of Boet :  I have made one refund my fund for an account send to my medical aid fund for hospital visitations to Boet -  on inspection of the duplicate account I noticed that Boet had already been discharged from hospital on the dates that the doctor specified  -  the fund also never picked up on it.  On the other account the receptionist told me that my fund did not approve for the procedure and that I had to pay for it as in immediate on the specific day.  Well, my child was in hospital and the procedure was important, so I paid up.  Got my statements back from the fund and what do I see ~  nice, a claim has been submitted to the fund for the same procedure, same date and same rate and the fund had paid for it, so did I.  Took the doctor on and made them refund me, including interest for the period.
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Offline Michael Alexander

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Re: MME Rates, PPR Rates and what the doctors charge
« Reply #1 on: August 01, 2011, 06:19:04 PM »
@Dalene, is'nt this what the GOv was moaning about recently, the unrealistic inflated prices being charged by GP's and the likes thereof...?

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Offline Dalene Steenkamp (Coetzee)

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Re: MME Rates, PPR Rates and what the doctors charge
« Reply #2 on: August 01, 2011, 06:55:43 PM »
Government is moaning about this, BUT they have a big hand in all of this.  Changing legislation i.e. healtcare on an annual basis, not committing to promises on GP's acting as state docs, enforcing certain limitations or sub-limitations by way of legislation on Medical Aid Funds, that force doctors to overcharge and loads of other stuff.  Smoke screen medicine price regulation ...,  forced controll over pharmaceutical issues etc etc etc

None the less  -  I have asked many times why do they still hang the Medical Credo of "I shall commit to saving life  blah blah" on their walls, for it should be changed to  'If you have money to pay, then I shall treat you or administer you to a hospital, but if you do not have money, you can pass my door and die out in the passage (that shall also cost you), but preferrably out in the street.'  Me, being me, have said that out loud in the hospital infront of doctors and nurses and I dared them to proove me wrong.   They said I am not allowed to make such statements, then I asked them if it would be okay to call the Volksblad to ask them to witness what was being said to me and other patients at the hospital.  For some reason, that specific evening I did not have to pay the doctor the cash fee of R800 to get into his car to drive 2km to the hospital and I only paid the normal after hours consultation emergency fees...   Makes you wonder, does it not??
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Offline Bertie Horak

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Re: MME Rates, PPR Rates and what the doctors charge
« Reply #3 on: August 02, 2011, 08:24:51 AM »
There is a different side to this though. MY side...
Here in my area:
90% plus people dont have medical aid.
There's ONE dentist who has to look after 3 towns and surrounding area for "state" patients in clinics.  If a child of 2 years old has toothache, they will probably be put on a waiting list, and be treated after about 4 MONTHS!!!  And no, the dentist can not be blamed, he has 2 hands.
The state (health department) do not want to create another post for an additional dentist to help carry the load. The state REJECTED my offer to work one day a week FOR FREE in their clinic to help those little ones, because I'm private, and not a state dentist...

Now the dilemma - THEY CAN NOT PAY FOR SERVICES, that's why they have to rely on the clinics.  BUT.... What do you think I feel like when they come to me with a screaming child??? I simply can not afford to spend an hour, and materials, injections, needles which cost a lot of money, (and which the state gives for free to the clinic) without getting paid a single cent.  So, in that case, should I then honor the words of Hippocrates, or go hungry? Wonder what the bank will say when I say, sorry I cant pay for my house this month because most of my patients couldn't pay me this month... 

The health system sucks, yes, but you also can not expect from a private practitioner to work without getting paid for services. Yes, you will get sharks out there who will charge whatever they want, and still sleep well at night, and then you'll get somebody like me who doesn't charge for consultations, and suffering because of it.
There IS NO MEDICAL AID TARIFF in 2011. Fortunately I only have a few medical aid patients, because claiming from a scheme is a nightmare. You have to charge what the medical aid decided is the right price, NOT a medical board or government. It took me more than a week to figure out which medical aids will pay what.
Simple example: A consultation on Medical Aid will be paid as follows by different shemes:
Medscheme - R144.90
Discovery - R154.30
Polmed - R147.00
Keyhealth - R143.70
Momentum - R142.40
Motohealth - R144.40
   ALL DIFFERENT, and that's only ONE tariff code for 6 medical aids. I work with a few HUNDRED tariff codes, and have patients on 30+ medical aids.  You go do the maths.   AND.. if I dont charge those fees that the scheme decided they will pay (even if the total is out by 1 cent), they often pay the patient, and not the doctor, so the practitioner will probably never see the money...

Just another aspect to think of. All is not rosy in a practice, and government funded clinics are not up to scratch, and the people are suffering.
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Offline Dalene Steenkamp (Coetzee)

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Re: MME Rates, PPR Rates and what the doctors charge
« Reply #4 on: August 02, 2011, 10:44:41 AM »
@ Bertie -  I know you are one of the honorable ones out there who does not go out for it to get the patient and fully understand your reason as explained.  My wrath goes toward those ones who do their utmost best to charge at the highest rate and I have experienced that on numerous occassions in the past two years.

As you will notice, I did mention that Government has a big hand in all the 'bad' service and the state GP's struggle to get their money out of Government, meaning that they run into debt in the end of the day.  A local doctor who used to be a state GP has cancelled his contract due to this issue and after 3 years he is still struggeling to get his money from Gov Health Dept.  I don't blame him for quitting  -  he was also one of those who did his best for patients, but got 'bitten in the heel' by the system.

I also know that it is a nightmare to get your payment from Medical Aid Funds sometimes.  I have had many fights with my fund over this issue  ~  they don't pay what they should and I have to fight to sort out the mess that they create for me.

I also have a big issue with GP's who DEMAND as cash payment of R800 to come out for an emergency call, even if you are on a medical aid fund.  They simply refuse to come out for the call if the cash amount is not paid.  That amount is not claimed from your medical aid fund.  Even after paying that amount, they still charge your medical aid fund for an after hours emergency call out, the hospital bills your fund for after hours emergency treatment.  What about the people who just don't have the cash to put down for a call out if they go to the hospital in the middle of the night with a sick child.  They are turned away.  I saw it with my own eyes and that is why I have made such noise and made those remarks.
Life becomes harder for us when we live for others, but it also becomes richer and happier. Friendship is a sheltering tree.

To be clever enough to get a great deal of money, one must be stupid enough to want it.

Those who bring sunshine to the lives of other cannot keep it from themselves.

Offline Bertie Horak

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Re: MME Rates, PPR Rates and what the doctors charge
« Reply #5 on: August 02, 2011, 11:28:36 AM »
Yes I agree and understand, Dalene.
Indeed, charging R800 for emergency is preposterous (ooh, love that word, try saying that without splattering all over your screen!), and as far as charging that ON TOP OF claiming an after hours fee from the medical aid, is totally unacceptable and illegal. Pity that there will always be some practitioners like that.  I suspect you have to know your patients as well. In the Cape I had to "up" my call-out fee and demand a payment upfront from certain people - that was the only way I could get rid of drunk party animals calling me out for an emergency at 2am on a Monday morning complaining of a terrible disease (and when you get there, the diagnosis is "alcohol consumption to the point of vomiting") and they just wanted to have a letter for work... or when you get there, it's a family fight and they need a councilor, not ME, or the best call-out I had... wait for this... husband calls me out, wife in terrible pain, they already called the ambulance... when I get there, her new DENTURE (yes false teeth) is hurting her... I kid you not, the ambulance DID arrive....
But yes Dalene, that was me in private practice.  If however I practiced in a hospital, OR offered my services to be called out for emergencies at a hospital, then it would have been my responsibility and duty to be there for ANY emergency when called out. And in that case as well, I am TOTALLY against any additional fees for the call-out. If the practitioner is asking a higher fee as the medical aid is prescribing, he should tell the patient about that, BUT must be prepared to wait for the patient to pay AFTER the service and AFTER HE SENT AN ACCOUNT.

As far as Government payments /departments are concerned, ask me!  I withdrew my service after 2 years.  I was contracted in by the defense force to see to their pensioners from the Northern suburbs' dental needs. It was a nightmare from the start, and even though the old folks were very glad they could come to me in stead of driving all the way to Wynberg military hospital, I had no choice but to stop the service. Try working when you haven't been paid by the Dept of Defense for 8 months, but in the mean time you have to pay the labs for all the dentures you've made in that time!!!

If the government really cared for the citizens,they would have taken their hands out from under their a**es and seen to getting proper services, fee structures (as in the past), and proper practitioners in state positions who actually WANT TO be there!!
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Offline Michael Alexander

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Re: MME Rates, PPR Rates and what the doctors charge
« Reply #6 on: August 02, 2011, 04:11:39 PM »
The thing that irks me, is when a person  has been involved in a serious accident, golden hour an all.... the hospital refuses to treat you unless payment has been forthcoming..... you are left to die until somebody coughs up...

Just my 2 cents....  are-you-there
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Offline Dalene Steenkamp (Coetzee)

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Re: MME Rates, PPR Rates and what the doctors charge
« Reply #7 on: August 02, 2011, 04:16:53 PM »
Yep, you cannot be admitted to hospital before you put down in cash R15 000  --  no, sorry, not a cheque and no, there is no electronic transfer facility availible at the hospital (oh yes, the first thing you grab when you rush to the hospital for an emergency is your laptop)  -   you have to pay cash upfront.  Seen that as well ....  it is sad, but it is a fact and the poor people getting the flack about it are the ones only getting a salary at the hospital  -  they are not on the board, nor do they decide about things like that  ---  the MIB of the hospitals are to blame, but you never see them or get to meet them.
Life becomes harder for us when we live for others, but it also becomes richer and happier. Friendship is a sheltering tree.

To be clever enough to get a great deal of money, one must be stupid enough to want it.

Those who bring sunshine to the lives of other cannot keep it from themselves.

Offline Bertie Horak

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Re: MME Rates, PPR Rates and what the doctors charge
« Reply #8 on: August 02, 2011, 07:00:37 PM »
Very true. As I understood it all those years, a private hospital HAS TO stabilize the patient before transferring to a state facility. But yes, looks like the fat cats share their cream with the people on the medical boards. The people who make the rules. The people who  turn their backs when it comes to patients.
I find it hard to believe that nobody has sued the hospitals for doing just that - turning critical patients away.
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Offline SandyB

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Re: MME Rates, PPR Rates and what the doctors charge
« Reply #9 on: August 02, 2011, 09:20:39 PM »
NOTHING BETTER THAN F...NG LEECHES ..  THEY POST HUGE PROFITS EACH YEAR ,, GUESS WHAT  JOHNS  FROM 20;00 TILL  03;00  TIME OF DEATH COST ??   R 23 000   SMACKERS  ... OK SURE  THEY DID EVERYTHING . ?? BUT HELLOO    IS THAT NOT EXCESSIVE , THE VULTURE MOST PROBABLY  RUBBED THEIR HANDS IN SATISFACTION   SAYING MM  DEAD MAN DOWN LETS LOAD IT ...
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Offline Michael Alexander

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Re: MME Rates, PPR Rates and what the doctors charge
« Reply #10 on: August 03, 2011, 12:58:12 AM »
In essence, it boils down to the shareholder?
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Offline SandyB

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Re: MME Rates, PPR Rates and what the doctors charge
« Reply #12 on: February 22, 2014, 10:31:16 PM »
I had  to go to periodontist  to have remedial work on my upper jaw due to chilhood injury that lay latent till about 3 years ago when another truama resurrected it .. in essence an abcess in the jaw bone that had to be gouged out and bone augmentation done , the bill  for dontist was 7800  for one + hours work , medical aid paid the grand sum of  ZAR 1900 , the wondeful lady who administered wonderful drugs for conscious aneasthesia  bill was 2200 I got paid out ZAR 1100 exactly half ..  I was informed that medical aids are opting out of dentistry on an ongoing basis .. even my gap cover would not  cover it ...   cheated , but yes agree prcings are way too high ,,
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Offline Bertie Horak

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Re: MME Rates, PPR Rates and what the doctors charge
« Reply #13 on: March 12, 2014, 02:51:25 PM »
All specialists can charge whatever they want, and since there is NO government control over medical aid tariffs anymore (the last 3-4 years), it's a headache to see ANY medical aid patient. I myself charge NINE different medical aid tariffs depending on which medical aid you are... The Medical Aid decides what they want medical aid tariff to be. If I charge one tariff to all medical aids, they will not pay, or pay portion only, OR like Discovery - pay INTO THE PATIENT'S bank account - try getting that money  ha ha
The patients' contributions to their medical aids have gone up by at least 15%, but their dental BENEFIT has gone DOWN.  For instance, 3 years ago, GEMS (Government Employees Medical Scheme) members' benefit per annum has gone from NO LIMIT on basic dentistry, to R1760.00 for the whole year...  Shocking!
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