Yes, a South African dental practice can charge more than a patient's medical aid pays, and bill the patient for the difference. The condition is that the patient knows your fee and the likely shortfall before treatment starts, and agrees to it in writing. The HPCSA calls this informed financial consent, and its 2024 billing guidelines set out exactly what it expects.
Most shortfall disputes are not about the amount. They are about the surprise. This guide covers what the rules say and how to build them into your front desk routine.
This is a plain-language summary of published guidance, not legal advice. Check your own billing policy with SADA, your indemnity provider or an attorney.
Why is there a shortfall at all?
Medical schemes pay their own rate for each procedure code, and your practice sets its own fee. When your fee is higher, the gap is the patient's to pay. Schemes say this openly in their own benefit guides. Discovery's 2026 dental guide, for example, describes a defined annual check-up on its Smart plans with a co-payment of R130 or R195 depending on the plan, and adds: "If your provider charges more than the DHR, you will be liable for the balance" (Discovery Health Medical Scheme, 2026).
Patients rarely read that line. So the conversation falls to your practice.
What does the law require you to tell the patient?
Two layers apply.
The Health Professions Act. Section 53 says a registered practitioner must, before rendering a service, tell the patient the fee they intend to charge when the patient asks, or when the fee is higher than the fee usually charged, in which case the patient must also be told the usual fee. It also requires a detailed statement of account within a reasonable period (HPCSA Booklet 19, June 2024).
HPCSA Booklet 19 on ethical billing. Published in June 2024, it goes further. It says practitioners must have "a fixed, transparent and documented billing policy", that patients must be aware of the fees before any fee-generating activity starts, and that "patients on a medical aid or similar product must be informed of the implications of the fee structure" on their ability to claim. It then requires that informed financial consent is obtained in writing (HPCSA, 2024).
In practice that means a written estimate, signed or acknowledged by the patient, before the work begins.
Can you bill the patient for the difference?
Yes, if you do it the right way. Booklet 19 draws a clear line:
| Practice | What it means | HPCSA position |
|---|---|---|
| Balance billing | Patient and scheme receive identical accounts showing the full fee, with the patient's portion specified | Acceptable |
| Split billing | Scheme is billed only what it will pay, patient is billed separately for the rest, neither sees the full fee | Not acceptable |
SADA has made the same point publicly: the HPCSA permits balance billing, it should be transparent and subject to informed consent, although some larger schemes have refused to accept balance bills (SADA, South African Dental Journal, 2021). How a particular scheme treats your account is between you and that scheme, but your duty to the patient does not change.
Can you ask a medical aid patient to pay upfront?
Only in specific situations. Section 12 of Booklet 19 says a practitioner "shall not charge fees for health services not yet rendered", except for:
- the cost of prostheses
- a co-payment at medical aid rates required from the patient
- a foreign patient receiving care in South Africa
- custom-made devices that cannot be used for or modified for another patient
So collecting a known scheme co-payment at the visit, or a laboratory fee for a crown before it is made, sits inside the guidance. Asking for the whole treatment fee in advance as a matter of routine does not obviously fit any of the listed exceptions. If your policy goes beyond them, check it with SADA or your indemnity provider first.
Should your practice check benefits on the patient's behalf?
This is where well-meant help causes trouble. The SADA dental mediator reported that about 47% of patient complaints received in 2015 related to financial consent and administration around medical aids, the largest category. The mediator's advice was that practitioners "should refrain from taking the responsibility to communicate with the medical aids on behalf of their patients", because benefits can change between authorisation and claim (SADA Dental Mediator, South African Dental Journal, 2015).
A safer pattern is to give the patient the procedure codes and your fee in writing, and ask them to confirm their own benefit and any co-payment with their scheme.
A front desk checklist for every estimate
- Your fee for each procedure, with the procedure codes
- A plain statement that the scheme may pay less and the patient is responsible for the balance
- Any separate costs you know about, such as laboratory, hospital or anaesthetist fees, or where the patient can get those figures
- How and when payment is due, including any co-payment collected on the day
- The patient's signature or written acknowledgement, kept in the record
- A note to update the estimate if the treatment plan changes
What if the patient still does not pay?
Booklet 19 says you may not withhold treatment outcomes or results because a fee is unpaid, and encourages practitioners to use legal debt collection. You may offer a payment plan with written consent, but may not charge interest on the debt, apart from a narrow case where the patient has not paid and the medical aid has also rejected the claim. It also expects "reasonable attempts" to engage the patient before formal collection begins (HPCSA, 2024).
Those reasonable attempts are where many practices run out of time. Remi's invoice chasing (PaidUp, R299 a month) sends polite, persistent reminders on unpaid accounts so the follow-up actually happens before you consider handing anything over.
Where the phone fits in
Many shortfall conversations start with a call: "Do you take my medical aid?" or "What will I pay for a filling?" Those questions need someone who knows your fees and the patient's file, not a guess. An AI receptionist for dental practices such as Remi can answer the line at any hour, book the consultation and take a detailed message for whoever prepares estimates, so the patient gets a proper written figure rather than a rushed one over the phone.
The short version
- You may bill above the scheme rate, but the patient must know your fee and the possible shortfall before treatment.
- Get informed financial consent in writing. A signed estimate does the job.
- Balance billing is acceptable. Split billing is not.
- Upfront payment is limited to the exceptions in Booklet 19, such as co-payments, prostheses and custom-made devices.
- Do not take on the patient's conversation with their scheme. Give them the codes and let them confirm.
- Chase unpaid shortfalls reasonably and in writing before using debt collection, and never hold back results.