Fees and Insurance
All you need to know about billing and coverage
FINANCIAL RESPONSIBILITIES
After you have provided all appropriate information through forms provided by our MPPO Clinic staff, our experienced office staff will verify your benefits with your insurance carrier to determine the amount of coverage available for your orthotic or prosthetic services. If needed, our staff will also obtain prior authorization from your insurance company. Our office staff will then be able to provide you with an accurate estimate of your portion of the costs prior to your orthotic and prosthetic service being provided. Payment for your personal or out-of-pocket portion is expected at the time you receive your service. At MPPO we attempt to exhaust all avenues before you would have to settle your account with a co-payment. We will often suggest a more cost-effective option or customize your payment terms.
MPPO accepts several methods of payment – debit-, credit card or electronic funds transfer.
As part of our commitment to service to you, we will make every attempt to verify your insurance benefits at the time your services are rendered. However, insurance verification or authorization is not a guarantee of insurance payment. This only allows our office to provide you with a preliminary estimate of any monies due by the insured on or before the time of delivery of the device. Your patient portion is subject to change based on final claim determination by your insurance carrier.
HOW INSURANCE IS HANDLED AT MPPO:
Most of the orthotic and prosthetic services provided by MPPO are covered by health insurance, including most medical schemes, depending on the benefit structure. The amount of coverage available for services can vary quite a bit depending on the type of policy you hold. If you have more than one insurance plan, it is possible that the entire cost of your care could be covered.
In some cases, some percentage of “co-pay” is required to be paid out-of-pocket by the patient at the time the orthosis or prosthesis is delivered. Before your first appointment, it is a good idea to consult with your medical scheme, or prospective insurance company, to understand exactly what benefits are available for O&P services.
Working closely with your healthcare team is also beneficial and can help to maximize your benefits.
Together we can assess your needs and abilities, which will assist in determining the most appropriate orthotic and prosthetic device for your lifestyle. This may also give additional leverage when working and/or negotiate with your insurance company.
WHAT IF MY MEDICAL SCHEME DOES NOT ALLOW FOR O&P SERVICES?
If you are a member of a medical scheme or underwritten by a policy that does not include an external assistive device benefit, like a hospital plan for example, you may still be able to receive funding from your medical scheme through a Prescribed Minimum Benefit Application (PMB).
In short, the South-African government approved legislation that governs medical schemes to fund a list of certain conditions regardless of what tier policy you are underwritten by.
Your MPPO Orthotist will be able to guide and motivate your case before the medical advisory board should you qualify for PMB funding.
For more information on PMB and how it works, click here.
Another method of obtaining funds from your medical scheme would be to apply for funding under an ex gratia application. These payments are assessed by the medical advisory board on a case by case basis and is granted as ‘’good will’’ by the medical scheme. For you to qualify for this type of funding, you would have to prove that you will not be able to fund your O&P treatment out of your own pocket. This usually entails you to provide the scheme with personal, financial documents to motivate your case. Your MPPO Orthotist will be able to guide you through the process of constructing such a motivation.
HAVE YOU SUFFERED AN INJURY AS A RESULT OF A MOTOR VEHICLE ACCIDENT?
In 1996 the South-African government launched the Road Accident Fund (RAF), that provides compulsory cover to victims of motor vehicle accidents on South-African roads. This also includes conditions that requires O&P services.
The MPPO team has extensive knowledge on how to get the most out of your RAF cover and will be able to guide you through the process.
HAVE YOU BEEN INJURED DURING WORK-RELATED ACCIDENT?
If you are employed in South-Africa, it is law for your employer to register you with the Workman’s Compensation fund. If you are injured at work or while performing your duty, the compensation fund will be able to assist you in funding your assistive devices.
MPPO is a registered provider with the compensation fund, and will be able to assist you with your claim.
What is prior
authorisation?
A certification or authorization that an insurer provides prior to medical service occurring and typically contingent upon eligibility, medical necessity, and benefits however not a guarantee of payment.
What is a
referral?
A recommendation to consult the (professional) person or group to whom one has been referred; “the insurance company says that you need a written referral from your physician before seeing a specialist”.
Payment
plans?
We understand that O&P services are expensive. Even more so when one did not anticipate the loss of a limb or disability. We also frequently encounter patients that would like to invest in more specialised componentry that is not covered by their conventional funding.
We are here to help, and assist with a payment plan.
