Revenue Assurance · Part 1 of 2

Doctor, Your Debtors Book May Be a PMA Control Problem

Most accounts receivable in a South African specialist practice is preventable — if the billing system was built to stop errors before they become rejections. This article explains what A/R really is, and what your PMA should be doing about it.

Let Us Start With the Real Problem

Your revenue objective as a doctor is not complicated. You want to:

• submit clean claims
• reduce avoidable rejections
• identify patient liability early
• prevent stale debtors
• improve cash flow
• reduce staff rework
• strengthen visibility over unpaid balances

Yet many South African specialist practices carry a growing debtors book — not because of reckless billing, but because the billing system was never built with enough controls to stop bad submissions from leaving the practice in the first place. That is the problem this article addresses.

Most Common Preventable Causes

• Claims submitted without a valid pre-authorisation or authorisation number
• ICD-10 and procedure codes that do not match the funder's current rules
• Prescribed Minimum Benefit (PMB) conditions charged to the patient's Medical Savings Account instead of the scheme's risk benefit
• Claims submitted after the funder's submission deadline has closed — rendering them time-barred and irrecoverable
• Undetected duplicate claims submitted without a cross-check

Medical Schemes Act 131 of 1998 — Section 29(1) and PMB Regulations: Medical schemes are legally obliged to fund Prescribed Minimum Benefit conditions from risk benefits — not from a member's Medical Savings Account. A PMA that does not flag this misrouting exposes the practice to claim reversals, patient disputes, and regulatory risk.

Illustrative example — Scheme rejection: A specialist submits a tariff for a planned procedure without the required pre-authorisation number. The funder rejects the claim on receipt. An amount of approximately R3,200 sits as scheme-side A/R. A staff member spends time reprocessing. The submission fee was charged regardless of the outcome.

PMA Controls Required for Scheme-Side A/R

• ☐ Hard stop on mandatory fields — submission blocked until patient ID, membership number, dependent code, ICD-10, tariff code, and authorisation number (where required) are all complete
• ☐ Pre-authorisation enforcement — a hard block, not merely a dismissible warning, until a valid authorisation number is captured
• ☐ ICD-10 and tariff code validation — incompatible code combinations flagged against the funder's current rules before submission
• ☐ PMB routing validation — system identifies PMB-classified conditions and blocks incorrect charging to the patient's savings account
• ☐ Duplicate claim detection — cross-check across patient, date of service, and procedure code before any submission is processed
• ☐ Daily rejection dashboard — each rejected claim shown with reason code, responsible staff member, correction required, and days unresolved

⚠️ Note: Patient-side A/R is almost entirely a point-of-engagement failure. Once the patient leaves the practice without a financial commitment in place, the probability of full recovery drops significantly — regardless of how aggressively the balance is later pursued.

Illustrative example — Patient-side A/R: A patient's savings account has been depleted by mid-year. The practice's PMA does not flag this at check-in. A specialist consultation of approximately R2,450 is billed post-service. The patient disputes the charge six weeks later, citing no upfront disclosure. The balance enters patient-side A/R at day zero — a situation the practice can take steps to prevent.

PMA Controls Required for Patient-Side A/R

• ☐ Real-time benefit verification at booking — confirms co-payment obligation, available benefit balance, MSA status, and network standing of the treating practitioner
• ☐ GAP cover and shortfall prompt — system asks about GAP cover status and generates an estimated patient liability figure so staff can communicate it before treatment commences
• ☐ Patient financial undertaking workflow — for uninsured or benefit-exhausted patients, documented financial commitment is required before the appointment is confirmed
• ☐ Co-payment collection prompt at check-in — collecting R350 at the front desk is straightforward; chasing the same amount six weeks later is a cost the practice absorbs entirely

The Override Log: Your Most Overlooked Control

Every time a staff member dismisses a system warning or bypasses a required field, your PMA should record who did it, when, on which claim, and what warning was overridden. You, as the practice principal, should review this log monthly.

Without it, you have no visibility into whether your controls are being respected — or quietly ignored. Your PMA should also split your aged debtors report into scheme-side and patient-side balances, broken down by funder, reason code, and age bucket. A single rand total tells you nothing actionable.

Question	Your Answer
Does my PMA block claims missing a required authorisation number?	Yes / No / Unsure
Does my PMA validate ICD-10 and tariff code combinations before submission?	Yes / No / Unsure
Does my PMA flag PMB conditions being charged to the patient's savings account?	Yes / No / Unsure
Does my PMA check benefit status and co-payment obligations at booking?	Yes / No / Unsure
Does my PMA prompt a patient liability disclosure for uninsured or GAP-exposed patients?	Yes / No / Unsure
Does my PMA maintain an override log accessible to me as principal?	Yes / No / Unsure
Does my PMA produce a rejection analysis by reason code and funder?	Yes / No / Unsure
Does my PMA split my debtors report into scheme-side and patient-side balances?	Yes / No / Unsure
Does my PMA require my written authorisation before a balance is written off?	Yes / No / Unsure

🚨 Red Flag Action: Five or more "No" or "Unsure" answers may indicate your PMA is not providing the controls needed to prevent avoidable A/R. Consider raising these points with your PMA provider in writing, requesting a written response on each, and — where the gaps are material — seeking an independent Revenue Leakage Review.

A/R is not always a collections problem — it is often a control problem. The next question is who should be collecting it once it has accumulated, and whether that person has the independence to tell you honestly what created it.

Continue to Part 2 of this series: Before You Hand Your Debtors Book to Your Billing System Provider →

Further Reading

For a step-by-step framework on managing outstanding accounts once A/R has accumulated: Medical Practice Debtor Management: The 30/60/90/120-Day Escalation Model →

References

• Medical Schemes Act 131 of 1998 — Republic of South Africa
• Council for Medical Schemes — PMB Regulations, Schedule 1 and Circulars
• HPCSA — Booklet 4: Ethical and Professional Rules of the Health Professions Council
• Board of Healthcare Funders of Southern Africa (BHF) — Billing Protocols and EDI Standards
• Institute of Internal Auditors — International Standards for the Professional Practice of Internal Auditing