It pays to question your medical bills

Too often, when it comes to medical schemes, members are intimidated into accepting bills that are ridiculously high or explanations that might not make sense. The two scenarios below show why it’s well worth your time to push back.

It’s Januworry – the month when your wallet seems permanently empty, the grocery cupboard looks sad and the only place you seem to have lots of money available is your medical savings.

I took my teen to the optometrist for his annual check-up. Cue a new pair of spectacles (his broke and he has been using an old pair) and he wants contact lenses now because, well, university.

Although this medical savings account does look flush this month, I’m well aware of how quickly those funds run out, particularly since I’m on chronic medication. (I managed to stretch it to September last year.)

So, after some discussion with my ex-husband, we reviewed the quote from the optometrist and decided we would each pay half in cash. I called back to let them know and, just in case, to ask if there would be any change to the quote.

Lo and behold, the consultation fee dropped from R872 to R300. That’s a 66% difference. Which just goes to show, it always pays to ask if there’s a discount (and have cash on hand).

You could also opt to settle the bill in cash, get the discount and then submit it to your medical scheme so it can reimburse you. Ask your medical scheme if this is an option. I can’t imagine that a medical scheme would prefer to be charged the higher price.

Discovery Health carries the can for R125-million error

In other medical scheme news, Discovery Health (the administrator) has accepted liability after a claims systems error resulted in scheme members’ above threshold benefits (ATBs) being overpaid.

The error affected 16,507 members across certain Executive, Comprehensive and Priority plans (all the most expensive plan options) where ATBs apply.

The Council for Medical Schemes plans to investigate the processes that led to an error in Discovery Health Medical Scheme’s administration – resulting in the 16,507 members suddenly being told that they owed the scheme significant amounts of money, up to as much as R80,000.

MediCheck, an independent medical scheme advocacy firm that assists members in disputes with their medical schemes, estimates the total value of disputed recoveries to be between R130-million and R170-million, based on the number of affected members and the range of individual recovery amounts reported.

However, Discovery Health placed the value at about R125-million, equivalent to about 0.1% of annual Discovery Health Medical Scheme claims. About R3.6-billion in benefits was paid out for the affected members over the course of last year, chief executive Dr Ron Whelan told Cape Talk on 6 January.

Discovery Health told Daily Maverick that the error originated after a system update in early 2025, and related to how certain medicine claims (over-the-counter medicine, non-preferentially priced medicine and ethical medicine) accumulated to the Annual Threshold and were paid from the ATBs. As a result, members reached their ATBs thresholds faster, which inadvertently resulted in the scheme paying for some medicines and services that should have been covered by these members.

“We detected the error through routine monitoring by the Discovery Health drug risk team and a single member query from a broker,” the administrator said.

Mark Hyman, chief executive of MediCheck, which represents more than 1,500 Discovery Health members, said the company’s announcement that it would absorb the full cost of the claims processing error rather than pursue recoveries from more than 16,500 members was a welcome one.

“The [Discovery Health] decision follows a week of intensive engagement by MediCheck on behalf of affected members who faced recovery demands – in some cases exceeding R80,000 – for an administration error they did not cause,” he said.

Members’ relief

Daily Maverick reader Lynette, whose surname has been withheld to protect her privacy, was among those affected.

“I am very relieved that Discovery have decided to take responsibility for its error and found the moral courage to do the right thing,” she said.

She noted that affected members were placed under unnecessary stress with Discovery Health’s “previous stance requesting (demanding?) that we bear responsibility to pay it back”.

“Let this be a lesson that public outcry and critical feedback and consumer activism, together with organisations like MediCheck and the media, which have the public’s interest at heart, do make a difference,” she told Daily Maverick. DM

This story first appeared in our weekly DM168 newspaper, available countrywide for R35.