Here are some useful questions and answers to help you understand the difference between split and balance billing:
| Practice | Split-billing | Balance-billing |
| Is it legal? | No | Yes, however, healthcare service providers on the GEMS Network have agreed to provide healthcare to GEMS members at Scheme Rates and therefore are not allowed to balance-bill. |
| What happens? | A healthcare provider submits two different accounts. One to you and another to GEMS, each with different costs. | A healthcare provider submits one account to you and the same account to GEMS with the same costs. |
| How this happens? | A doctor's consultation fee is R500. The doctor submits an account of R300 to GEMS to be paid from your available benefits. The doctor then submits a different account to you for the remaining R200, which is more than likely not covered by your available benefits. Both you and GEMS are unaware of the split in the amounts that is required to be paid to the doctor. | A doctor submits an account of R500 for his consultation fee to you and GEMS, and ensures that there is transparency in the request for payment to be made. The doctor's account may specify the amount that GEMS must pay and the amount that you must pay. In this example the doctor would not be a GEMS GP network doctor, because they have agreed to a set consultation rate so you don't incur any co-payments. |
What should yo do? | Should you receive an account that you believe has been split billed by a healthcare service provider, please contact the GEMS Fraud Hotline by calling 0800 21 22 02 or send an email to [email protected] with the details of your claim. GEMS will then contact the service provider and address the error with them. |
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