Free tool
Scheme rate checker
A claim priced above a scheme’s rate is usually not short-paid. The whole line is redirected to the member and the practice receives nothing — so being a few percent over costs you the entire payment, not the difference. Paste codes off a remittance you already have and see where you stand. It runs in your browser; nothing you type is sent anywhere.
One code per line: code, your price, scheme allowed. Take the allowed amount from a line the scheme actually paid — a redirected line shows zero and tells you nothing about the rate.
Why a few percent costs you everything
When a scheme responds paid claim to member, it has not rejected the claim and the patient’s benefit has not run out. It has decided to settle with the member instead of you. The work was done, the coding was accepted, and the money went to the patient’s bank account. You are now an unsecured creditor of your own patient for the full amount.
Across 180 days of claims we process, this affected 5,301 claim lines across 210 practices, carrying R3.4 million of billed value. The practice received nothing on 100% of them. Not a reduced amount — nothing.
The part worth sitting with is how small the cause usually is. Where the billed price explains the redirect, the practices we looked at were typically only 3% to 14% over the rate. These are not practices overcharging aggressively; they are practices running a slightly stale pricelist. The trigger is tiny and the consequence is total, which is the worst possible shape for a problem to have, because nothing about it feels urgent until you add up a year of it.
Each scheme’s own tariff schedule and remittance advice are the authority on its rates. This tool holds no rate table of its own and cannot tell you what a scheme pays — it compares the two numbers you supply and explains what the gap between them means.
What to do about it
1. Work from a remittance, not from a rate card you were once sent
The authoritative number is what the scheme actually allowed on a line it paid you. Rate cards go stale, differ by plan, and are often the thing that drifted in the first place.
2. Fix the pricelist, not the claim
A redirected line is not worth re-submitting at a corrected price — the scheme has already made its decision on it. What is worth doing is correcting the code’s price so the next hundred claims pay to you, and then collecting the redirected ones from the patients who received the money.
3. Check the codes you bill most, not the expensive ones
The cost is volume multiplied by the whole line value, so a routine code you send four hundred times a month is worth far more attention than an occasional large one. Sort by how often you bill it and start at the top.
4. If your price is at or below the rate and it still redirects
Then price is not your problem and correcting the pricelist will not help. A redirect that price cannot explain usually attaches to the practice rather than to the line, and the right next step is asking the scheme directly why payments are being made to members.
Related reading: how to read a remittance advice, why medical aid claims get rejected, and the ICD-10 claim checker for the coding side.
Frequently asked questions
What does "paid claim to member" mean on a remittance?
It means the scheme has decided to pay the patient rather than the practice. The claim was not rejected and the benefit was not exhausted - the money was simply sent somewhere else, and the practice now has to collect it from the patient. The most common trigger is a billed price above the scheme's rate for that code.
If I bill 10% above the scheme rate, do I lose 10%?
No, and this is the part that surprises people. You lose the whole line. It is a cliff rather than a sliding scale: across the redirected lines we measured, the practice received nothing at all on 100% of them. A few percent over the rate costs the entire direct payment on that line.
Where do I find what the scheme actually allows for a code?
On your own remittance advice, on a line the scheme paid. Take a claim that was paid to the practice, find the code, and use the amount the scheme allowed. Do not use a line that was redirected to the member, because that shows zero paid and tells you nothing about the rate.
Does this tool tell me the scheme rate?
No, and deliberately so. It ships no rate table. Scheme tariff schedules are the schemes' own material, and the rates we derive from adjudications are how our in-app pricing report works. This tool compares two numbers you already have and tells you what the gap means.
Is every redirected payment caused by price?
No. Price explains most of what we see, but not all of it. Where a practice is only a few percent over the rate, a pricelist correction fixes it. Where the billed price is at or below the rate and payments are still redirected, the cause is usually something attached to the provider rather than the line, and that is a conversation to have with the scheme directly.
Is anything I type here sent anywhere?
No. The comparison runs entirely in your browser. Your prices are commercially sensitive and nothing you enter is transmitted, stored or logged.
Have this checked for you, every month
NetPractice sees what every scheme actually paid on every one of your claims, so the codes you are pricing above rate can be found without you pasting anything. R9.50 a claim, first 10 each month free, no monthly fee.