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We have health problems that require occasional hospital care by teams of medical practitioners. Over the past few years I have been told by doctors’ receptionists that our fund, Latrobe Health, are very slow to pay bills. Yesterday I found that a cardiologist who provided excellent in hospital care in September 21 has not yet been paid for this. I have provided this feedback to LHS with no response. I find this extremely embarrassing. Does anyone know whether other PHIs are prompt with payments? I will switch insurers if I know my doctors’ accounts will be paid in a timely manner.
Welcome back @lg16447
I have moved your post into this specific topic about Latrobe PHI, Thank you for your feedback about your experience and I hope others might be made aware of possible issues. To find a product that suits you, you may try by using the Federal Government’s Health Fund comparison site and CHOICE provided reviews of the functioning of health funds. CHOICE has recently posted a review of the highest complained about PHIs at Australia’s most complained about health insurance funds | CHOICE
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While it may be embarrassing, it is really not one’s responsibility when an health insurer pays the benefits directly to a doctor/specialist. I wouldn’t be overly concerned if they are being tardy paying the cardiologist and Latrobe Health meets your own health insurance needs.
I don’t know when other insurer pay benefits to a doctor/practitioner and haven’t ever asked if the doctor has received the benefits. I always assumed those who can claim electronically, the claimed benefits/funds would be transferred soon there after.
I think in regards to PHI and payments to a provider of a service is that the user of the service remains responsible for the cost until the PHI reimburses the provider. The contract of insurance is between the user of the service ie the patient and the insurer. The Insurance company can have a contract between the company and the provider which sets a standard level of payment expected if a fund user uses that provider eg No Gap providers.
What the fund member is able to do is hold the Insurer responsible for the fund’s failure to carry out their contract agreement. I know this from an experience we had with our insurer at the time, this led to us having legal demands for us to pay the health provider for the service they provided. It was an expensive process and at the time involved debt collectors contacting us in regards to the outstanding amount. We paid the cost in the interests of removing the debt and eventually received reimbursement from the fund. We now refuse to use PHI companies, we either go public or fund the procedure ourselves.
Some health providers are happy to wait longer periods for reimbursement than others, usually a fund is expected to disburse the amount within 35 days (from what I understand) unless further information about the claim is required. The Insurer is supposed to keep the insured party aware of any reason that the payment is unduly delayed or refused. If payment is refused the Insured are entitled to seek review of the decision and if unsatisfied with the review or another matter with their PHI which has not been satisfactorily resolved can make a complaint to the Commonwealth Ombudsman who has responsibility for PHIs. Private Health Insurance - Commonwealth Ombudsman
Just as a For Your Information (FYI) to anyone reading this topic:
In regards to PHIs, AFCA do not have a role to play in a dispute, they are for other forms of insurance eg Life Insurance, General Insurance, retirement funds (Superannuation) and other financial products like banking.
I just checked one of our HICAPS (electronic claim) receipt from a relatively recent claim through our health insurance. The receipt gives the total cost if the service and the gap amount (difference being the benefit paid by the health insurer. The receipt also says claim has been approved through the HICAPS provider system - which indicates that the benefit is now payable to the provider…and the amount if the benefit to the provider. This suggests using HICAPS, the insurer is now responsible for the benefits payment not the patient.
A provider will also have a contract for payments through HICAPS from the insurer. The payment could be tardy through HICAPS or the insurer not releasing the approved funds. Both not the responsibility of the patient/policy holder.
What is interesting is HICAPS has a credit licence. I expect other electronic claim systems would be similar where they are the finance party.
I was thinking the only way the policy holder would be responsible if the provider didn’t use an electronic claim system or the heath insurer didn’t…and old paper claim system was used to process the claim. While possible, it is unlikely as the patient would need to pay fully for the consultation and then claim benefits through lodging a claim separately with the insurer, where the insurer reimburses the benefit back to the patient/policy holder.
Another scenario could be the doctor has agreed for payment to be deferred until such time reimbursement of benefit occurs, to minimise out of pocket to the patient…but, our own insurer needs evidence payment has been made before a benefit is reimbursed. This seems to eliminate this scenario.
HICAPS is a middleman in that they get approval from the fund and then send this approval to the health care provider. They have an agreement between them and the insurer to cover the costs of providing this service.
The actual period of when the fund disburses the amount to the provider through HICAPS system varies with the terms stating
“5.5 Subject to clause 5.8, where a Fund authorises a Transaction Request or Cancel Request, it must calculate for each day the following:
T - C
T = the total of amounts the Fund has authorised for payment as a result of each Transaction Request made on the relevant day;
C = the total of amounts the subject of each Cancel Request which is authorised by a Fund and which has not previously been the subject of settlement under this clause.
5.6 Each Fund must pay to You the amount calculated for the purposes of clause 5.5 within 10 Business Days of the day for which the amount is calculated or other period reasonably agreed with You, if that amount is a positive amount. If the amount is a negative amount then it must be paid by You to the Fund within 10 Business Days of the day for which the amount is calculated in the manner agreed between them or other period reasonably agreed with the Fund.”
If the fund subsequently refuses the claim then HICAPS can take money from a balance payable to the provider, to reimburse the fund.
“5.8 Where a Fund has settled a Transaction Request pursuant to clause 5.6, the Fund may require You to pay back the amount relating to the Transaction Request if the Transaction Request is not valid or acceptable and the Fund may direct HICAPS to debit the account nominated by You for settlement adjustments.”
HICAPS is not provided for every service nor is it used by every health provider.
In the case mentioned by @lg16447 if HICAPS had been used the payment to the provider of the health service should not be still outstanding, payment is relatively fast ie end of month, within days, or some similar agreed period but definitely not 6 or so months. It is treated by a provider, that if it is an approved transaction, as it had been paid similar to if they had been paid by debit card or a credit card, but they must wait for the usual disbursement of funds.
The fact it is outstanding shows that it is a payment that has not been approved yet, is delayed because it has been lost in Latrobe’s processes, or is not covered by Latrobe. If HICAPS has been used then the payment may have been the subject of a Cancel Request or has subsequently been found to be a payment not covered by the fund. This all leaves the patient responsible for the outstanding amount.
The provider in @lg16447’s case may be negotiating an outcome, if it is unsuccessful @lg16447 will be required to pay. This then requires @lg16447 to seek a review of the decision and if necessary go to the ombudsman if unhappy with the review.
I have a different view. These are payment systems used by health insurers, and operate similar to a point of sale payment system. Using an analogy, if one pays by credit card tor a fridge using a credit card and the card issuer takes months to release funds for the fridge after payment was approved, could the seller chase the consumer because they haven’t received payment through the payment system…no…as the payment tor the fridge was approved by the payment system. Responsibility transfers to the payment system to ensure payment is processed and the seller receives the funds. The health insurance payment system is no different.
If the claim was declined through the payment system, then it would remain the responsibility of the patient, to differently to a eftpos type console indicating payment for the fridge is declined.
It isn’t paid, the transaction receives a request approval, HICAPS do not pay the money, it is simply an intermediary in the transaction. The approval may subsequently be rejected which our’s was. The health fund during the period of when they have to settle may cancel the request approval and not pay. They inform the insured and the provider. Notice from 5.8 that the HICAPS transaction is simply a transaction request “Where a Fund has settled a Transaction Request” it isn’t referred to a payment. We had to pay then we had to fight the insurers. We won or actually received an ex gratia payment in the end but it was painful and expensive in the meantime.
When we started to involve the C’wealth Ombudsman, the problem was seemingly not so much a problem anymore just a simple misunderstanding. I and my wife no longer have any faith in the PHI system. We save to meet those expenses we feel may need a choice of quicker treatment eg my wife’s recent eye op. We pay out of our health savings for these. Everything else is public. I also found that paying the way we do, we have almost always hit the extended safety net in the year. Far less out of pocket than if we were still in a fund.
Others experience differs and they may and do have a different view of health funds, including some of my children who go to the public system because they can’t afford the private treatment due to the health fund premiums, yet they continue to pay the premiums. Others get great benefits from their PHIs, I don’t dispute this. Our experience has soured us about it.
In my limited experiences HICAPS has been extra providers, not hospital or surgeon. Is focusing on HICAPS a furphy? They billed outside HICAPS regardless if the fund or patient received the bill. Does ‘one size’ apply?
I am of the opinion it may likely not been HICAPS as the period is far past their usual standards of payment periods.
Regardless of this, if it was HICAPS I am just noting that HICAPS is not a payment. It is purely a Transaction Request that payment has yet to be paid for. In the period between the request and the payment the fund may not approve the payment. If this happens the patient (insured person) is required to make the payment. The fund is required to inform the insured that payment of the claim is not approved. The insured can then go through the process of review by the insurer and complaint to the Ombudsman. We thought our claim would be settled on review, it wasn’t which led to our experience of who in the end is responsible.
@PhilT HICAPS can cover Medical centres, doctors, and ancillary health services (Extras). I don’t think hospitals are on it yet unless they use Medicare payments in which case your Medicare rebate can be claimed.
HICAPS is a wholly owned subsidiary of NAB. NAB plans to merge HICAPS and LanternPay (which they entered into a contract to buy in January this year) to create an even bigger system.
Latrobe would be a user of the HICAPS systems, as I understand that 100% of funds have joined them.
While it doesn’t make the payment, like a point of sale machine it facilitates payment from the insurer to the provider.
What I don’t understand is the HICAP system obtains data from the insurer in relation to cover, caps and possible claim amounts (based on past claims and caps) from the insurer, which then provides information at the time the transaction is processed that the claim is approved or rejected. If the HICAP receipt indicates that the receipt is approved, then this is based on the insurer’s data and information on the policy held by the patient.
I wonder if there has been an oversight by the HICAP operator, where a claim may have been rejected but not checked or mistakenly thought to have been approved by the insurer.
The HICAP system also allows the provider to cancel an approval. This could be where they have decided to waive fees for some reason after the consultation (maybe the treatment which was ineffective, through renegotiation of fees by the patient or mistakenly claimed items).
That is my understanding as well. There are other systems as well such as Healthpoint which is owned by the Commonwealth Bank. They seem to operate like EFTPOS consoles where there are many providers of such consoles, but they effectively function the same and use the same data sources.