Who is responsible to pay for Private Ambulance Services?
In short, the patient or the next of kin is the person responsible to settle any account for paramedical care and ambulance transportation, irregardless if you called or not.
If a patient is on a medical aid / medical scheme, the ambulance service will either submit the claim to the scheme directly, or to the patient / next of kin / main member to settle and then claim back from the scheme.
If the patient is not on a medical scheme / aid, then the patient will be responsible to settle the amount.
A service has been delivered to the patient, and this needs to be paid for.
Gone are the days of “oh this must be for free”. Ambulances can cost from R500 000 to well into the millions. Staff, equipment and many other items also cost money. Very few private ambulance services have any government funding, and if they do it is usually for specific requirements.
When you go to the shops to buy food or water or anything else, you pay for the services there and then as the items and related services costs money to bring them to you.
Emergency case cover.
If your emergency falls within the PMB (Prescribed Minimum Benefit) list, then your scheme is obligated to cover the charges, however there may be short falls / co-payments for the patient which the scheme does not cover.
Non-Emergency cases.
Cases where a patient does not need emergency care, or the injuries or illness of the patient fall outside of the PMB list, nearly always need pre-authorisation for payment or the patient is responsible for the costs.
Examples:
Patient has a possible heart attack - this is a PMB and should be covered
Patient injured in a Motor Vehicle Accident - this is a PMB and should be covered
Patient has a headache - this will not be covered unless the headache is related to an emergency condition such as a Stroke.
Transportation from hospital to the patient home - your medical scheme will most likely not authorise this.
Transport from hospital to a rehabilitation centre - your medical scheme should cover it if it is within the PMB list
Transport from home to another home address for social reasons - your scheme will not cover this.
How long does my scheme have to settle the claim.
As per the Council of Medical Schemes (CMS), the medical scheme must settle the claim within 30 days of correct submission to the scheme. After this 30 days the patient would be liable to settle the amount.
Can any ambulance service claim from a Medical Aid?
NO, not all ambulance services can claim from your medical aid. There are stringent criteria the ambulance service must conform to:
The service must be registered with the Department of Health in their province.
The service must be registered with the Board of Healthcare Funders of South Africa (BHF)
Both the above require certain standards to be upheld, with minimum items of equipment, staffing, cleaning, oversight and others. You must be registered with the Department of Health to be able to register with the BHF
A registered service can claim from a Medical Scheme, Workman’s Compensation, Road Accident Fund and others.
No BHF registration, means no ability to claim and the patient is liable for the costs.
Ensure your preferred ambulance service, is registered with the Department of Health as a minimum before using them.
If the service is not registered with the Department of Health as a minimum, you can report this service to your provincial Department of Health, Ambulance Inspectorates.
What are the costs/charges for?
The costs or charges are for the level of care the patient received and the time used for the paramedics and ambulance. It is also for the equipment, disposables and other items used on or for the patient. (like Personal Protective Equipment - PPE)
A medical aid may short pay if the ambulance service was on scene for an extended time. This extended time may not be the ambulance service’s fault, and could be due to carrying a patient down many flights of stairs, or waiting for additional help to arrive to treat the patient appropriately. The patient would be responsible for the shortfall in payment. (this is only one example)
Co-Payments
In some instances, the medical scheme does not settle the full amount or has items which the specific scheme does not cover. In this case the patient is responsible to cover this amount. This is the same as going to see a doctor or specialist. Your medical aid may only cover a portion of your doctors care and treatment.
A co-payment can range from a few rand, to several thousand, depending on what your specific scheme sees fit to cover.
How can you avoid paying Co-Payments / Shortfalls.
There is no simple way to not pay them, ultimately the patient is responsible for the full costs of the case in full, even if the scheme pays or not.
After being assisted by an ambulance service, follow up on your account.
Find out if it will be submitted to you or to the scheme
Follow up on the account 30 days later with the ambulance service
Provide the ambulance service with your email address and correct contact details, so they can advise you if the scheme did not settle the account.
It is the patient / main members responsibility to follow up on this. Failing to settle the account could mean that you are handed over to a collection service, or even worse blacklisted on ITC for non-payment.
However having a gap cover could allow you to claim some of it back, alternatively having an ambulance membership (with your preferred and local ambulance service) could cover the shortfalls or even cover the full transportation if not covered by the scheme. visit www.immediatemedical.co.za/memberships
NB - Immediate Medical Memberships are powered by IMC Assist. www.imc-assist.co.za
If you would like more information, please do not hesitate to contact us on email info@immediatemedical.co.za / www.immediatemedical.co.za