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Legislation Applicable on Credit Management in the Healthcare Practice

  • Health Professions Act, 1974, Act No 56 of 1974
    • Section 53: Fees charged by registered persons
    • Regulations in terms of the Health Professions Act, 1974, Act No 56 of 1974
  • Medical Schemes Act, 1998, Act No. 131 of 1998
    • Section 59. Charges by suppliers of service
  • Regulations in terms of the Medical Schemes Act
    • Regulation 3: Proof of membership
    • Regulation 6: Manner of payment of benefits

Ethical Guidelines Applicable on Credit Management in the Healthcare Practice

  • General
  • Ethical Tariffs
  • Recovery of collection fees
  • Final notice re collection of fees
  • Listing of “bad debt” patients
  • Session of book debts
  • Refusing to see patients due to non-payment of accounts
[u_heading]Legislation Applicable on Credit Management in the Healthcare Practice[/u_heading]

Health Professions Act, 1974, Act No 56 of 1974

Section 53: Fees charged by registered persons

(1) Every person registered under this Act (in this section referred to as the practitioner) shall, unless the circumstances render it impossible for him or her to do so, before rendering any professional services inform the person to whom the services are to be rendered or any person responsible for the maintenance of such person, of the fee which he or she intends to charge for such services –

(a) when so requested by the person concerned; or

(b) when such fee exceeds that usually charged for such services, and

shall in a case to which paragraph (b) relates, also inform the person concerned of the usual fee.

(2) Any practitioner who in respect of any professional services rendered by him or her claims payment from any person (in this section referred to as the patient) shall, subject to the provisions of section 32 of the Medical Schemes Act, 1998 (Act No. 131 of 1998), furnish the patient with a detailed account within a reasonable period.

(3)

(a) The patient may, within three months after receipt of the account referred to in subsection (2), apply in writing to the professional board to determine the amount which in the opinion of the professional board should have been charged in respect of the services to which the account relates, and the professional board shall, as soon as possible after receipt of the application, determine the said amount and notify the practitioner and the patient in writing of the amount so determined: Provided that before the professional board determines the said amount, it shall afford the practitioner concerned an opportunity to submit to it in writing his or her case in support of the amount charged.

(b) ………

(c) The Minister may, after consultation with the council, make such regulations as he or she may deem necessary in relation to the procedure which a professional board shall follow in disposing of an application under this subsection.

(d) A professional board may from time to time determine and publish the fees used by the professional board as norm for the determination of amounts contemplated in paragraph (a). [

(4) A claim which is the subject of an application referred to in subsection (3) of which notice has been given by the professional board or the patient to the practitioner, shall not be recoverable until a determination has been made in terms of that subsection, and when such a determination has been made no amount which exceeds the amount so determined, shall be payable: Provided that if the patient has paid to the practitioner an amount in settlement or part settlement of such claim and such amount exceeds the amount so determined, the practitioner shall pay the amount by which that payment exceeds the amount so determined back to the patient. [

(5) This section shall not be deemed to divest a professional board of any of its powers or functions under Chapter IV with regard to acts or omissions in respect of which it may take disciplinary steps.

(6) For the purposes of this section “professional services” shall include the supply of any artificial part for the human body and the fitting of such part to the human body

 

Regulations in terms of the Health Professions Act, 1974, Act No 56 of 1974

  • On 23 July 2010 Regulations relating to fines which may be imposed by a Preliminary Committee of Enquiry or a Professional Conduct Committee on practitioners found guilty of improper or disgraceful conduct under the Health Professions Act, came into effect. These Regulations set out a range of minimum and maximum fines that may be imposed when a practitioner has been found guilty of unprofessional conduct or has elected to pay an admission of guilt fine.
  • Minimum and maximum fines for the listed acts of improper or disgraceful conduct applicable on the collection process are as follows:
    • overcharging, minimum fine R 5 000 and maximum fine R 15 000;
    • over-servicing, minimum fine R 20 000 and maximum fine is the amount claimed for over-servicing plus 5% of such amount or R 20 000, which ever is the greater;
    • negligence or fraud, minimum fine R 20 000 and maximum fine R 70 000;
  • The fines are payable in respect of one or more charges. Therefore, the fines may be compounded. For example, if a practitioner is charged with overcharging five patients, she / he may be faced with a cumulative fine of R 75 000.00.

 

Medical Schemes Act, 1998, Act No. 131 of 1998

Section 59. Charges by suppliers of service

  • A supplier of a service who has rendered any service to a beneficiary in terms of which an account has been rendered, shall, notwithstanding the provisions of any other law, furnish to the member concerned an account or statement reflecting such particulars as may be prescribed. (Subsection 1)
  • A medical scheme shall, in the case where an account has been rendered, subject to the provisions of this Act and the rules of the medical scheme concerned, pay to a member or a supplier of service, any benefit owing to that member or supplier of service within 30 days after the day on which the claim in respect of such benefit was received by the medical scheme. (Subsection 2)
  • Notwithstanding anything to the contrary contained in any other law a medical scheme may, in the case of –
    • any amount which has been paid bone fide in accordance with the provisions of this Act to which a member or a supplier of health service is not entitled to; or
    • any loss which has been sustained by the medical scheme through theft, fraud, negligence or any misconduct which comes to the notice of the medical scheme, deduct such amount from any benefit payable to such a member or supplier of health service. (Subsection 3)

Regulations in terms of the Medical Schemes Act

Regulation 3: Proof of membership

Every medical scheme must issue to each of its members, written proof of membership containing at least the following particulars:

  • the name of the medical scheme;
  • the surname, first name, other initials if any, gender, and identity number of the member and his or her registered dependants;
  • the membership number;
  • the date on which the member becomes entitled to benefits from the medical scheme concerned;
  • if applicable, details of waiting periods in relation to specific conditions;
  • if applicable, the fact that the rendering of relevant health services is limited to a specific provider of service or a group or category of providers of services; and
  • if applicable, a reference to the benefit option to which the member is admitted.

Regulation 6: Manner of payment of benefits

  • A medical scheme must not in its rules or in any other manner in respect of any benefit to which a member or former member of such medical scheme or a dependant of such member is entitled, limit, exclude, retain or withhold, as the case may be, any payment to such member or supplier of service as a result of the late submission or late re-submission of an account or statement, before the end of the fourth month:
    • from the last date of the service rendered as stated on the account, statement or claim; or
    • during which such account, statement or claim was returned for correction.
  • If a medical scheme is of the opinion that an account, statement or claim is erroneous or unacceptable for payment, it must inform both the member and the relevant health care provider within 30 days after receipt of such account, statement or claim that it is erroneous or unacceptable for payment and state the reasons for such an opinion.
  • After the member and the relevant health care provider have been informed of the unacceptable account such member and provider must be afforded an opportunity to correct and resubmit such account or statement within a period of sixty days following the date from which it was returned for correction.
  • If a medical scheme fails to notify the member and the relevant health care provider within 30 days that an account, statement or claim is erroneous or unacceptable for or fails to provide an opportunity for correction and resubmission, the medical scheme shall bear the onus of proving that such account, statement or claim is in fact erroneous or unacceptable for payment in the event of a dispute.
  • If an account, statement, or claim is correct or where a corrected account, statement or claim is received, as the case may be, a medical scheme must also dispatch to the member a statement containing at least the following particulars:
    • the name and the membership number of the member;
    • the name of the supplier of service;
    • the final date of service rendered by the supplier of service on the account or statement which is covered by the payment;
    • the total amount charged for the service concerned; and
    • the amount of the benefit awarded for such service.
[u_heading]Ethical Guidelines Applicable on Credit Management in the Healthcare Practice[/u_heading]

General:

One of the functions of the Health Professions Council is to uphold and maintain professional and ethical standards within the health professions [section 3(m)]. Ethics are defined as “moral principles”. Within the health care field there are standards which must be met and maintained with regard to ethics. To this end the Health Professional Council of South Africa has formulated a set of rules (Ethical and Professional Rules of the Health Professions Council of South Africa) regarding professional conduct against which complaints of professional misconduct will be evaluated. These rules are reproduced in booklets. We highlight various ethical aspects applicable on the collection process in the medical practice.

 

Ethical Tariffs:

  • The Health Professions Council of South Africa (HPCSA) has taken a decision to scrap its ethical tariffs used by doctors as a ceiling for patient accounts. As a regulatory body aiming at protecting the public consumers of healthcare services, the HPCSA still retain its authority to determine whether a practitioner has overcharged a patient or not, in terms of Section 53 of the Health Professions Act 1974. In order to make this determination, the HPCSA has adopted (26 November 2008) the following principles:
    • a practitioner shall charge a non-insured patient the NHRPL rate except where the patient provides written informed consent for a billing higher than the NHRPL rate and any charge above the NHRPL rate without the patient’s consent shall be deemed to be overcharging;
    • a practitioner may charge a private-paying insured patient a rate payable by the Medical Scheme to which that patient belongs or is a member if it is higher than the NHRPL rate provided that any rate higher than the rate payable by the Medical Scheme shall be deemed to be overcharging, except where the patient has given written informed consent for a charge higher than the Medical Scheme rate; and
    • for the purposes of determining whether the patient has provided informed consent, the practitioner is required to indicate to the patient the prevailing NHRPL or Medical Scheme rate for whatever procedure the patient presents for as well as the difference between that rate and the rate the practitioner intends to charge as well as the amount that the patient may have to pay in addition to the stipulated rate.

 

Recovery of collection fees:

In April 1981 the Medical and Dental Professions Board of the Health Professions Council of South Africa decided that expenses incurred in connection with the collection of an account may not be added to the services rendered and that this ruling should not be interpreted as if such expenses may not be recovered. A practitioner should not hand over an account for collection before all attempts have been made to obtain payment in the usual way.

 

Final notice re collection of fees:

In October 1986, in reply to a patient who advised that he had been threatened with court action if he did not bring his account up to date, Council advised the patient that Council did not see any objection to a practitioner sending a final notice if the payment for an account remained outstanding for a considerable period.

 

Listing of “bad debt” patients:

The Medical and Dental Professions Board confirmed in February 2022 its previous resolutions regarding the listing of “bad debt” patients, namely:

  • there was no objection to a practitioner subscribing (i.e. receiving on a regular basis upon payment or otherwise) to lists, published by any agency, of persons who represented a bad risk financially, in view thereof that a practitioner was free to decide to whom he or she wanted to render services;
  • a practitioner could, however, be called upon to justify his or her action in the event of unnecessary suffering or death resulting from his or her refusal to render help to a patient;
  • a practitioner was also obliged to render assistance under all circumstances in emergencies. However, it was only permissible for practitioners to furnish information on their own “bad debt” patients to agencies for inclusion in a list if such a list was intended solely for circulation amongst practitioners registered with the Council, since this could be regarded as being of inter-collegial interest and assistance;
  • patients could, therefore, only be listed on a “closed user group” database at the request of a particular practitioner if such a list was intended solely for circulation amongst practitioners registered with Council;
  • should a practitioner decide to list a “bad debt” patient on a “closed user group” database, such patient should be informed in writing of such action by the “listing agency” concerned;
  • should there be a dispute between the practitioner and the patient concerned regarding an outstanding debt, such patient should not be listed until the dispute had first been settled
  • practitioners and not the “listing agency” should decide whose name should be listed;
  • a patient should be properly informed by the practitioner concerned about the implications should his or her name be listed before such action was taken. Prior to treatment, a practitioner should make full details available to the patient regarding the cost of treatment;
  • a practitioner should not refuse treatment to a patient at the request of another practitioner to whom that patient was indebted.

 

Session of book debts:

The Executive Committee of the Medical and Dental Professions Board resolved in June 2011 that:

“A practitioner would remain responsible for his or her own accounts in respect of professional services rendered by him or her, including the collection of monies from patients in settlement of such accounts, whether or not a cession of the whole or a portion of such practitioner’s book debts had been affected. The Board does not express a view on financial arrangements which practitioners make with financial institutions in respect of such accounts, saving to record that the practitioner would remain personally and professionally responsible and accountable to the Board and to his or her patients in respect of these accounts”.

 

Refusing to see patients due to non-payment of accounts:

In August 2000 the Executive Committee of the Medical and Dental Professions Board resolved that:

  • a medical practitioner or dentist had the right to refuse treatment to a patient, but he or she could be held professionally accountable should that patient unduly suffer or die because of his or her refusal to treat the patient concerned; ]
  • possible complications or interruption of treatment of a patient, especially of a child, should be fully explained to the patient or parent;
  • a doctor may consider legal remedy to encourage a patient to pay his or her outstanding account, but the consequence of such action should be fully explained to the patient;
  • a medical practitioner or dentist may under no circumstances refuse to treat a patient in the case of an emergency.

The Constitutional Court in Soobramoney v Minister of Health (Kwazulu-Natal) helped define what emergency medical treatment means in terms of section 27(3) of the Constitution. The applicant was suffering from renal failure which required on-going dialysis treatment in order to keep him alive. Mr. Soobramoney claimed that because the treatment was life-saving, it should be considered “emergency medical treatment” which cannot be refused. The Court, however, said that “emergency medical treatment” refers to treatment that is necessary because of a “sudden catastrophe which calls for immediate medical attention”. A person suffering from a treatable but incurable condition, such as renal failure, does not fall within the protection of section 27(3) of the Constitution, but is instead protected by the obligations imposed on the state by section 27(2), which requires the state to take all reasonable measures to ensure access to health care services is progressively realised.