Sisonke Health poor response

On 11 December 2023, Dischem submitted a claim for medication prescribed by Oncologist, Dr F Michaelis for Ritha Ramsuchit (medical aid number P3387727 & ID number 660922 5150 087, ICD code 50.9)). The claim was submitted by Dischem online on the 11 December 2023. The script copy for the claim of 11 December 2023 is attached.

On the 13 June 2024, I (Dhunraj Ramsuchit) was informed by Dischem that no payment was received from Sisonke Health for this treatment that was sent to Dr Michaelis oncology centre and so Dischem blocked the profile. This prevents Dischem from going into the profile to process another claim for the Stradexa tablets requested by Dr Michaelis on 04 June 2024 for Ritha Ramsuchit.

I enquired from Dischem to clarify when and how the claim of 11 December 2023 was submitted to Sisonke Health. The response from Dischem is quoted as follows : “The date on the script copy that I sent through is the date the claim was processed.

It dials through automatically as it is an online claim. We had a look and it showed that the claim went through on the oncology benefit and there was no levies due by member however, when our finance department went through all of the claim payments from the medical aid they noticed that there was no payment made from the medical aid for that claim.

They also contacted the medical aid but did not receive any feedback as to why they never paid the claim.”

The script copy was submitted by myself to Sisonke Health on 14 June 2024 to process together with my plea and context: “ps. The invoice was previously submitted online by Dischem but Dischem has not received payment as yet. The patient (my wife), Ritha Ramsuchit, is an oncology patient. She had a mastectomy of the left breast on 29 April. Her family has a long history of cancer where three of her siblings had passed-on from cancer. Dr Michaelis had prescribed further medication (Stradexa) for her treatment. Dischem is not in a position to process any further medication until outstanding amounts are settled. I am a pensioner and your urgent attention to this matter will be highly appreciated.”

On 19 June 2024, Sisonke Health responded with the following: “Kindly be advised that the account for Dis-chem direct oncology dated 11/12/2023 has been received and will be submitted for processing in accordance with the Scheme Rules. Kindly note that the claim is older than 120 days and is now considered stale. Kindly forward proof of previous submission for the claim to be submitted for stale claim review.”

This response from Sisonke Health was poor as the original submission was made by Dischem online on 11 December 2023 and further, the script copy was already provided to Sisonke Health by myself as well. I nevertheless again checked with Dischem on any further proof of submission. Dischem were taken aback by this request and again explained that the online claim should have been received by Sisonke Health on the same day, that is 11 December 2023. Sisonke Health would also have received other similar claims before and after 11 December 2023 from Dischem through this mechanism that were settled.

I reverted to Sisonke Health on 20 June 2024 to please advise whether Sisonke Health received the online claim of 11 December 2023 from Dischem.

I did not get an answer to my question.

On 24 June 2024, I received a notification from Sisonke Health stating that “A claim for 2023/12/11 to the value of R 2495.55 from DIS-CHEM DIRECT ONCOLOGY PHARMACY for Ritha Ramsuchit has been received and processed. Ref: 2024-1884826”

On 28 June 2024, I received a notification from Sisonke Health stating that “Kindly be advised that the proof of previous submission has been received and it will be submitted for stale claim review.”

My question whether Sisonke Health received the online claim on 11 December 2023 from Dischem remained unanswered.

On 28 June 2024, I received a further notification from Sisonke Health stating that “A claim for 2023/12/11 to the value of R 2495.55 from DIS-CHEM DIRECT ONCOLOGY PHARMACY for Ritha Ramsuchit has been received and processed. Ref: 2024-1922118”

I checked with Dischem and Dischem did not receive any payment from Sisonke Health for the claim of 11 December 2023.

On 03 July 2024, I received a notification from Sisonke Health stating that “Kindly be advised that the account for Mrs RITHA RAMSUCHIT SERVICE date 11/12/2023 has been received and will be resubmitted for reprocessing in accordance with the Scheme Rules.”

This has left us frustrated especially considering that Sisonke Health processed the claim on 24 June 2024 (ref: 2024-188426) and processed the claim on 28 June 2024 (ref 2024-1922118) and on 03 July 2024 Sisonke Health will be resubmitting for reprocessing.

On 03 July 2024, I made payment to Dischem for the 11 December 2023 claim.

The patient (my wife), Ritha Ramsuchit, is an oncology patient. She last received oncology treatment medication on 25 March 2024. She had a mastectomy of the left breast on 29 April 2024. Her family has a long history of cancer where three of her siblings had passed-on from cancer. Dr Michaelis had prescribed further medication (Stradexa) for her treatment on 04 June 2024. Dischem is not in a position to process any further medication until outstanding amounts are settled. Waiting for Sisonke Health to reprocess the claim of 11 December 2023 is hurting and disrupting her oncology treatment.

On 04 July 2024, I received a notification from Sisonke Health stating that “Kindly note the account for services rendered by Dis-Chem Direct Oncology Pharmacy on 11/12/2023 has been processed in accordance with the Scheme rules as the Stale claim has been approved and is awaiting a payment date.”

On 04 July 2024, I received a statement from Sisonke Health stating that the claim from Dischem Direct Oncology for 11 December 2023 has been rejected because - “Claim received after valid claim period as specified in scheme rules.”

My question whether Sisonke Health received the online claim of 11 December 2023 from Dischem remain unanswered. This claim should have been received by Sisonke Health at about the same time on the same day, 11 December 2023.

It is vitally important to know what went wrong.

My wife, Ritha Ramsuchit is expected to go on oncology treatment for the next ten years. During this time, we would be relying on the same system. If there is an issue, it needs to be identified so that processes can be put in place to prevent recurrence. Ritha Ramsuchit is dealing with the emotional and physical trauma of mastectomy that she had undergone on 29 April 2024. She has family history where three of her siblings passed away from cancer. The uncer*****y surrounding the processing of oncology treatment is agonising for us.

The responses from Sisonke Health has been rigid, lacks empathy and resembles a robotic system. Typically saying “claim received and processed according to scheme rules.”

While this is fine, it does not answer burning questions such as whether the online claim was received by Sisonke Health on 11 December 2023 or not.

If the claim was not received by Sisonke Health on 11 December 2023, then what went wrong with the online system.

If the claim was received by Sisonke Health on the 11 December 2023, then why was the claim not then processed in accordance with the scheme rules.

Attempts to contact Sisonke Health via Whatsapp has not been fruitful. For example, on 03 July 2024 at 08h53 I requested to speak to an agent. I was given a ticket reference number #977019. I am still waiting for an agent.

Sisonke Health your full and speedy response is awaited.