Direct billing

What actually happens at the counter

The provider swipes the card against the TPA's system, the system returns an eligibility answer, and for anything beyond a routine consultation the provider sends a pre-approval request. Approval comes back with what is covered and what the member owes. The member pays that share and leaves.

Where it breaks down

Pre-approval is the failure point, not eligibility. A member with valid cover at a direct billing provider can still be asked to pay in full if the treatment needs approval and the approval has not come back — evenings, weekends and public holidays are when this happens. The plan is working as designed; the client experiences it as the card being declined.

Direct billing is a network property

Whether direct billing is available is decided by the provider's arrangement with the TPA, not by the generosity of the plan. A comprehensive plan at a provider outside the TPA's direct billing network is a reimbursement claim.