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SPLIT BILLING VERSUS BALANCE BILLING EXPLAINED




Split billing

Explanation

Split billing is when two different accounts are rendered - one to the patient (like an admin fee) and another to the patient’s medical scheme. This method of billing is not allowed according to the Medical Schemes act and the rules and regulations of the HPCSA.

For example: The total treatment fee is R700. The physiotherapist submits an account of R500 to the scheme for payment and a separate account to the patient for the remaining R200.

 

Balance billing

Explanation

All transactions are reflected on one account. The same account is rendered to both the patient and then to the patient’s medical scheme. This method of billing is legal.

For example: The physiotherapist submits the account of R700 for treatment to the patient and the patient’s scheme. The account specifies the amount that the scheme must pay (R500) and the amount that the patient must pay (R200). All the transactions are on the account and the exact same account is send to the patient and the medical aid.




 

Split billing is illegal in terms of the following laws

According to the National Health Act (Act 61 of 2003) and section 53 (1)(b) of the Health Professions Act 56 of 1974, providers are required to disclose and obtain agreement on the cost implications of treatment from their patient and their patient’s Scheme before the consultation and/or treatment is to begin. 


In terms of the Medical Schemes Act 131 of 1998, a healthcare practitioner is required to reflect the full cost and nature of the service rendered on all accounts and is not permitted to charge a patient an amount upfront without that amount being included on the statement sent to the medical scheme and/or the patient. 


Consequences for Healthcare professionals

Professionals that are found to be split-billing will be requested to correct their behavior, failing which they will be reported to the HPCSA.

 

NOTE

Physiotherapists that have signed a Scheme specific network agreement (e.g. JSP contract from Discovery Health) have contractually agreed not to balance-bill patients. Consequently, if a contracted physiotherapist is identified to be balance-billing, the scheme has the right to remove them from the network. In this way, the scheme can effectively reassure their members that they will not incur any unnecessary out-of-pocket expenses.

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