Why medical claims are short-paid.
Short-payment is quieter than rejection and easier to miss, which is exactly why it costs practices more.
A rejected claim announces itself. A short-paid claim does not. Money arrives, the account is marked as paid, and the difference between what was billed and what was received sits in a remittance nobody reads line by line.
Where the gap usually comes from
- The claim was paid at a different tariff from the one billed
- Part of the claim was paid from a benefit that had already been partly used
- A co-payment or deductible was applied under the member's option
- One line of a multi-line claim was rejected while the rest was paid
- The claim was assessed against day-to-day benefits rather than PMBs
Why it compounds
A single short-payment is small enough to ignore. The same short-payment repeated across every claim of that type, every month, is not. Because each individual instance looks trivial, the pattern is rarely spotted until somebody reconciles properly.
What to do about it
Reconcile line by line rather than at total level, group the differences by cause instead of by claim, and query the cause rather than the individual claim. Fixing one recurring cause is worth more than chasing fifty individual shortfalls.
This article is general information about healthcare administration in South Africa. It is not legal, clinical or financial advice, and it does not describe the rules of any particular medical scheme. Always check the position that applies to a specific claim.