More than two months after Bonitas moved its administration from Medscheme to Momentum Health Solutions and its managed-care function to Private Health Administrators (PHA), the worst of the disruption appears to be over – but providers and members are still dealing with unpaid and short-paid claims, authorisation problems, tariff discrepancies, and delays in getting issues resolved.
There has been clear improvement since the 1 June “clean cut” transition. Calls are being answered faster, hospital authorisations are being processed, and claims are being paid. Bonitas says its operations have stabilised significantly, and member perceptions of its service have improved.
But those improvements have not removed the problems providers are still reporting.
The Radiology Society of South Africa (RSSA), which represents radiologists and has been engaging with Bonitas, Momentum Health, PHA, and Health Calibrate since the transition, says the initial problems have “not been substantially resolved”. These include short-paid and unpaid claims, authorisation-related rejections, inconsistent tariff application, old claims still needing to be reconciled, limited information on the Provider Zone, and poor call-centre support.
“The initial problems have therefore not been substantially resolved,” says Dr Richard Tuft, executive director of the RSSA.
A source who asked to remain anonymous because of the sensitivity of the issues and their escalation to other professional bodies also described a similar mix of improvement and frustration. The source has professional experience dealing with healthcare providers and direct experience of Bonitas from the provider and member sides.
The initial problems with the systems and PHA’s managed-care function have improved significantly, but claims are still being incorrectly processed or paid, while some PMB authorisations remain difficult to resolve.
Bonitas says the scale of the recovery is reflected in the numbers. Between 1 June and 31 July, it handled 342 419 member calls, processed 45 450 hospital authorisations, provided chronic medicine to 166 791 members, and paid more than R2.9 billion in claims. Average call-answering times improved by 79%.
More than 600 employees were recruited, onboarded, and trained as part of the recovery programme, with additional claims assessors and back-office staff brought in. Bonitas also says independent survey results show a 20% improvement in members’ perception of its service, particularly around authorisations and managed care.
The immediate crisis has eased. The question now is how quickly the remaining problems can be sorted out – and whether providers and members will see the improvement in the day-to-day handling of their claims, authorisations, and queries.
Providers are still chasing payments
Bonitas says claims processing and provider payments have stabilised significantly since the early stages of the transition.
Claims are being processed and paid daily, with more than R2.9bn paid during June and July. Additional claims assessors and operational staff have been added to deal with outstanding exceptions.
But Bonitas also acknowledges that some claims still need further review because of data, tariff, or other administrative issues.
That is consistent with what the RSSA is hearing from radiology practices.
Its members continue to report short-paid and unpaid claims. The RSSA says the consistency of those reports across practices and regions suggests a systemic problem rather than a handful of isolated cases.
It believes differences between the tariff files or Rand Conversion Factors used across the PHA, Health Calibrate, and Momentum Health systems are a significant cause.
The anonymous healthcare professional describes similar problems, including account short payments caused by incorrect tariff processing and difficulty getting those payments sorted out.
Bonitas says where a provider or member raises a concern about a particular claim, there are escalation processes in place to deal with it.
And where an administrative or claims-processing error results in an incorrect payment, Bonitas says the case is reviewed and corrective action taken where appropriate.
It also says members should not be unfairly prejudiced by an administrative processing problem.
The RSSA takes a similar position on incorrectly short-paid claims: where the problem is caused by an incorrect tariff file, RCF, code mapping, or processing error, the claim should be corrected and the provider paid.
It says it has not received evidence that practices are generally passing those erroneous shortfalls on to patients.
Radiology is still working through the tariff problem
Radiology has become one of the clearest examples of what remains unresolved.
The RSSA supplied Bonitas’ existing 2026 radiology tariff files and Rand Conversion Factors (RCFs) to Momentum on 3 June. Momentum subsequently told the RSSA that these had been accepted by Bonitas and loaded, apart from one PET-CT code.
Yet practices continued to report short-paid claims and other payment discrepancies.
As recently as 14 August, the RSSA says, Momentum indicated that feedback on rate adjustments was still awaited.
The RSSA says different RCFs apply depending on the member’s benefit plan and the imaging modality. It is working to ensure that the radiology benefits that applied before the transition continue to be applied correctly and consistently.
The RSSA says its understanding was that the existing 2026 Bonitas RCFs would continue to apply during the transition.
Bonitas says it continues to honour its contractual commitments and that payments are administered according to applicable provider agreements and agreed payment arrangements. For specific payment arrangements, however, it refers providers to Momentum Health and PHA.
Bonitas also acknowledges that providers have raised queries about radiology tariffs and payment outcomes. It says these are being investigated to establish whether differences relate to contractual arrangements, system configuration, claims-submission requirements, or processing rules. Where corrective action is required, it says this is implemented through the relevant operational channels.
The authorisation problem has changed, but it hasn’t disappeared
Hospital authorisations were among the biggest problems in the first weeks after the switch.
There has been progress. Bonitas processed more than 45 000 hospital authorisations in June and July and says authorisation and managed-care services have improved significantly.
The RSSA agrees that things are better.
But its members are still reporting that some pre-transition authorisations are not recognised. Authorisation numbers on the Provider Zone can differ from those on authorisation letters, and claims can be rejected for “no authorisation” even where a valid authorisation was obtained.
There are also cases where incorrect treating-provider or facility information prevents a claim from matching the authorisation.
Fixing these problems can mean repeated calls and lengthy follow-up.
PMB authorisations are an especially sensitive area.
The anonymous healthcare professional says most radiology information can now be loaded online, but turnaround times remain slow. Getting a confirmed PMB condition authorised by telephone can still take weeks or, in some cases, months.
The RSSA has not separately quantified how many of its reported authorisation problems involve PMBs. It says, however, that an administrative problem should not prevent a member from receiving the benefits to which they are entitled.
Bonitas says PMB-related cases receive focused attention through dedicated clinical and operational teams. Where delays are identified, cases can be escalated for expedited intervention.
Emergency claims are another unresolved question
There is also a concern around emergency and casualty claims.
The anonymous healthcare professional told Moonstone that a contact at a private hospital had reported a significant problem with unpaid emergency-room claims since the transition.
The source would not identify the facility, and Mediclinic did not respond to Moonstone’s request for comment.
The source also said that some private practices were reluctant to treat Bonitas members, while others were asking members to pay cash upfront and claim the money back from the scheme.
Bonitas says it remains committed to ensuring access to emergency medical care and that emergency claims are processed according to the scheme’s rules and legislative requirements.
It says it has continued engaging with hospital groups and healthcare providers about operational problems arising from the transition. Where specific emergency or casualty claims are raised, these are investigated through its existing escalation and payment-review processes.
The source said private facilities in the area are still treating Bonitas members, but concerns about outstanding claims remain.
Bonitas is also aware that some members experienced problems with providers, authorisations and claims during the early stages of the transition. It says these cases are being monitored and escalated where access to care is affected, particularly where treatment is clinically urgent.
Members are still feeling the effects
The problems on the provider side are showing up in members’ experiences too.
The anonymous healthcare professional says a family member who belongs to Bonitas has experienced problems with medication payments and the Health Benefit Booster, including over-the-counter medication being rejected as member liability despite money remaining in the benefit.
That is one member’s experience and cannot establish a wider trend.
Bonitas says it is aware that some members experienced problems with medication claims and certain benefit categories during the early stages of the transition.
It says most of these problems have since been addressed through system improvements, operational interventions and additional resources, while remaining issues continue to be monitored.
But communication is still a recurring complaint.
The anonymous provider describes incorrect claims payments and “little to no communication” about member and provider queries as among the biggest unresolved problems.
The RSSA is also still hearing complaints about poor call-centre support and inadequate information on the Provider Zone.
Better than June, but not there yet
There is no question that Bonitas has moved a long way from the first weeks of June.
The numbers show it. Claims are being paid, authorisations are being processed, chronic medication is reaching members and call-answering times have improved sharply.
Bonitas says the operation has stabilised and that member perceptions of its service are improving.
Neither the RSSA nor the anonymous healthcare professional is disputing that there has been progress.
What they are saying is that the remaining problems are now showing up in the details: the tariff loaded against a claim, the authorisation that does not match the system, the payment that is short or missing, the old claim that still needs to be reconciled, and the query that takes too long to resolve.
The South African Medical Association (SAMA) has also declined to comment for now. It says its leadership is due to meet with Bonitas to discuss challenges experienced by its members and that it would be premature to comment before those engagements have taken place.
The RSSA’s assessment is perhaps the clearest measure of where things stand.
“The practical measure of whether the transition has stabilised is whether practices can obtain reliable authorisations, submit claims, receive correct payment, and reconcile their accounts. On that measure, the transition is not yet operating at an acceptable level.”
