CLAIMS HOUND SERVICES

We get medical & insurance claims paid and treatments approved.

GET UNPAID CLAIMS PAID

Your medical costs have not been paid in FULL by the: 

Medical Scheme 

GAP Cover Insurance Company 

Medical Insurance Company

Claims Hound can help.

  • We engage with the Medical Scheme/Insurer on your behalf to get outstanding amounts paid.
  • No need for you to get directly involved in the dispute with the Medical Scheme/Insurer.
  • We notify you when the Medical Scheme/Insurer agrees to increase the benefits payable.
  • The increased amount will be paid either to you or the medical service provider depending on the rules of the Medical Scheme/Insurer.
  • On confirmation by the Medical Scheme/Insurer that payment has been made Claims Hound will invoice you for 15% of the increased amount (our service fee).
CONTACT CLAIMS HOUND TO START THE PROCESS

EXTENDED BENEFITS FOR HIGH-COST TREATMENTS

You can’t get the treatment or medication prescribed by your doctor because the Medical Scheme/Insurer refuses to approve the benefits at the appropriate level. 

 You are expected to make unreasonable co-payments or forgo the treatment altogether.

Claims Hound can help.

  • We engage with the Medical Scheme/Insurer on your behalf to get the extended benefits approved.
  • No need for you to get directly involved in the negotiations with the Medical Scheme/Insurer.
  • The increased amount will be paid either to you or the medical service provider depending on the rules of the Medical Scheme/Insurer.
  • On confirmation by the Medical Scheme/Insurer that payment has been made, Claims Hound will invoice you for 15% of the increased amount (our service fee).
CONTACT CLAIMS HOUND TO START THE PROCESS

MEDICAL SCHEME STATEMENT ANALYSIS

Medical Scheme statements can be confusing and are often complicated especially following hospitalisation, or treatment that extends over long periods of time (Cancer treatment).  

Some of the reasons claims are not paid in full from general funds are:

  • The treatment is not identified as a Medical Emergency when it should be.

  • The treatment is not recognised as a PMB when it should be.

  • Payments were incorrectly made using MSA money.

  • The Diagnostic Invoices (Radiology and Pathology) were captured prior to the invoices from the treating Service provider.

  • The medical service provider used the incorrect procedure or ICD10 code.

  • The Medical Scheme used the incorrect Price File.

  • The invoice was captured incorrectly.

  • Morphology codes are omitted.

Claims Hound can help.

  • We critically analyse your statements and identify amounts that may be payable to you.
  • You are provided with a detailed report to assist you in getting these amounts paid.
  • Claims Hound Charges R20 per Medical Scheme Statement page with a minimum of R50 to do the analysis and provide the report.
  • On receipt of the report, you can then decide to recover the amounts yourself or you can appoint Claims Hound to do so on your behalf.
  • If you appoint Claims Hound to act on your behalf to recover the amounts due our fee is 15% of the amounts recovered.
CONTACT CLAIMS HOUND TO START THE PROCESS

RECOVER AMOUNTS INCORRECTLY PAID FROM MEDICAL SAVINGS ACCOUNTS (MSAs)

Medical The money in the Medical Savings Account belongs to the member, and not the Medical Scheme. It is effectively a bank account. Sometimes Medical Schemes make payments from the MSA that should have been paid from the Scheme’s funds. This often happens after hospitalisation and major medical procedures. These incorrect payments can be claimed back.

Claims Hound can help.

  • We analyse your Medical Scheme Statements and Medical Service Provider Invoices to determine if the treatment qualifies for payment from general funds.
  • We engage with the Medical Scheme on your behalf to get the monies refunded to your MSA.
  • No need for you to get directly involved in the negotiations with the Medical Scheme.
  • You will be notified when the Medical Scheme agrees to make refunds to your MSA.
  • On confirmation by the Medical Scheme that funds have been refunded to your MSA, Claims Hound will invoice you for 15% of the increased amount (our service fee).
CONTACT CLAIMS HOUND TO START THE PROCESS

INCREASED BENEFITS FOR PRESCRIBED MINIMUM BENEFITS (PMBs)

Prescribed Minimum Benefits MUST be paid in FULL by the Medical Scheme under certain conditions. This applies to all Benefit Options. For example, Members who have a Hospital Plan are entitled to the same PMB benefits as the members who belong to the most expensive option.

Claims Hound can help.

  • We analyse your Medical Scheme Statements and Medical Service Provider Invoices to determine whether the treatment qualifies as a PMB, and if it should be paid in full.
  • We engage with the Medical Scheme on your behalf to get the treatment classified correctly.
  • No need for you to get directly involved in the negotiations with the Medical Scheme.
  • You are notified when the Medical Scheme agrees to increase the benefits payable.
  • The increased amount will be made either to you or the medical service provider depending on the rules of the Medical Scheme.
  • On confirmation by the Medical Scheme that payment has been made, Claims Hound will invoice you for 15% of the increased amount (our service fee).
CONTACT CLAIMS HOUND TO START THE PROCESS

LODGING COMPLAINTS WITH MEDICAL SCHEMES AND INSURERS

Where a Medical Scheme/Insurer has not paid a claim in full a complaint may be lodged. 

This is a complex process with specific time frames, procedures, and formats which must be adhered to. 

Failing to comply with the process and time frames may result in you losing your claim.

Claims Hound can help.

  • You appoint Claims Hound to handle the Complaint.
  • We engage with the Medical Scheme/Insurer on your behalf.
  • No need for you to get directly involved in the dispute with the Medical Scheme/Insurer.
  • We provide you with regular progress updates.
  • On confirmation by the Medical Scheme/Insurer that payment for increased benefits has been made Claims Hound will invoice you for 15% of the increased amount (our service fee).
CONTACT CLAIMS HOUND TO START THE PROCESS

COMPLAINTS AND APPEALS TO THE COUNCIL FOR MEDICAL SCHEMES (CMS)

If you are unsuccessful in getting your claims paid by engaging with the Medical Scheme or where the Medical Scheme refuses to provide approval for the benefits you require you may lodge a complaint to the Council for Medical Schemes (CMS). 

This is a complex process, and you need to ensure that your arguments are well presented, with supporting documentation and references if you want to be successful. 

Further appeals are possible should you be dissatisfied by the decisions of the CMS. 

Failing to comply with the process and time frames may result in you losing your claim.

Claims Hound can help.

  • You appoint Claims Hound to handle the Complaint on your behalf.
  • You provide with all the relevant information and documentation.
  • We draft and submit the complaint to CMS.
  • We deal with any queries CMS may have.
  • We provide you with regular progress updates.
  • If the CMS ruling results in increased benefits payable to you or the Medical Service Providers, Claims Hound will invoice you for 15% of the increased amount (our service fee).
CONTACT CLAIMS HOUND TO START THE PROCESS
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