DESIGNATED SERVICE PROVIDERS (DSP)

Genesis has DSP contracts with the Departments of Health in Gauteng, the Western Cape and the Northern Cape.

The Medical Schemes Act (“the Act”) is the legislation governing all aspects of a medical scheme. This Act defines some 270 mostly hospital-based illness conditions as Prescribed Minimum Benefits (“PMBs”). According to the Act, Genesis must provide funding benefits for these conditions, regardless of the benefit option you have chosen to join. In addition to this list of 270 conditions, there are a further 25 chronic conditions which must also be covered by Genesis and, in fact, by every medical scheme.

At the time, Government made it clear that the very purpose of identifying PMBs was to prevent medical schemes from designing their benefit options that excluded these very expensive and often serious medical conditions.  Had this been the case, members would be forced to go to public hospitals and the medical scheme would refuse to pay, on the grounds that there was no provision for such benefit(s) in its rules. 

The Act further prescribed that when any member of a medical scheme obtains treatment for a PMB illness condition in a public hospital, the medical scheme must reimburse all claims submitted by the public hospital at its published Uniform Patient Fee Schedule (UPFS) tariff that applies to all public hospital patients.  In other words, the idea is to prevent the unfunded dumping of members on public hospitals.

The Act prescribes that medical schemes are not allowed to limit reimbursement for the treatment of PMB illness conditions when they are obtained from a public hospital.

The obvious question then is, “What is the difference between being treated for a PMB illness condition in a public hospital and a private hospital?”

The first important point to remember is that private hospitals are not permitted to employ doctors. Public hospitals, by contrast are permitted to and they do employ doctors, who are paid by the state.

Private doctors work for themselves and charge for their services independently of any hospital. Therefore, when members are treated in a private hospital, each and every provider that provides any treatment or service, is a separate private (profit making) entity.

A typical procedure in a private hospital may result in Genesis receiving separate claims from various providers, such as the hospital, the treating surgeon, the assistant surgeon, the anaesthetist, the radiologist, the pathologist, the pharmacy and so on. Each claim is separate from the other and each provider may charge whatever fees they wish.

In regard to PMBs, the Registrar has previously ruled that Genesis, in the absence of a DSP, must pay each PMB claim in full, irrespective of what the provider has charged. One such outrageous claim that we shared with our members before, was when a provider demanded a fee to the equivalent of R61,000 per hour!

Genesis has entered into tariff agreements with private hospitals. This means that the whole private hospital claim will usually be paid in full. Although Genesis has tariff agreements with all the private hospitals, the Scheme has not negotiated separate agreements with the approximately 23,000 private doctors, as it is just not practical. To this end, the scale of benefits (“Scheme Tariff”) serves to limit the reimbursement of any doctor or other service provider that seeks to charge above the Genesis scale of benefits.

If you are treated in a public hospital for exactly the same condition, the claims submitted are charged at the published UPFS tariff that includes all doctors, the hospital and in fact, every provider or service that is administered to you.

Understandably, it is not feasible for medical schemes to pay doctors the equivalent of R61,000 per hour. Therefore, the rules have a scale of benefits (tariff) to limit the amount that doctors will be paid. The reimbursement level for members of the Private Choice option is 100% of the scale of benefits (“Scheme Tariff”). On all other benefit options the rate of reimbursement is 200% of the scale of benefits (“Scheme Tariff”).

Unless this limit is imposed, medical schemes are at the mercy of that group of doctors that seek to exploit the “pay in full” directive of the Council for Medical Schemes.

It is worth noting that section 29(1)(q) of the Act prescribes that medical schemes must include in their registered rules just such a tariff or scale of benefits to limit the amount that medical schemes are expected to pay to settle claims.

Simply put, if you are diagnosed with a PMB illness condition and you choose treatment in a public hospital, then Genesis cannot limit the reimbursement of your claim, provided that the treatment you receive is the same treatment that is available to any patient that does not have medical aid. Under these circumstances, your claim from the hospital (including treatment by all doctors, radiologists, pathologists, etc.) will be paid in full.

Kindly note that a referral protocol is applied in the public sector at hospital level, unless it is an emergency.

If, however, you choose to be treated in a private hospital for one of the PMB conditions, then your claim will be subject (and may be limited) to the benefits that apply to your selected benefit option, as detailed above.

All Genesis benefit options make provision for all private hospital accounts relating to the treatment of PMB conditions to be paid in full (except for specific exclusions listed in the rules, or in the case of personal expenses).

It is important to remember that, unlike treatment received in a public hospital, your private hospital account does not include charges for your treatment by doctors (or other healthcare providers). These charges are billed for separately by each and every provider independently of the hospital claim. In regard to these service providers (the doctors etc. not the hospital), the limits as set out in the rules of Genesis will apply. According to these rules, Genesis will reimburse claims at 100% of the scale of benefits (“Scheme Tariff”) for members on the Private Choice option and at 200% of the scale of benefits (“Scheme Tariff”) on all other benefit options.

In summary thus far, if you choose treatment of a PMB illness condition in a private hospital and your doctor charges more than the Genesis tariff, you will be liable for the co-payment (difference in cost).

Although the majority of doctors’ charges usually fall within the Genesis tariffs, there may be some doctors who will charge above these rates. It is therefore important that you find out from the doctor(s) that will be treating you in hospital as to what their charges will be and that you are aware of any co-payments that may apply.

Absolutely not!

The choice of where you wish to be treated will always be yours and yours alone to make.

Some doctors are taking advantage of the Council for Medical Scheme’s ruling that medical schemes must reimburse all PMB claims in full, no matter how excessive and / or outrageous the doctor’s charges may be. We have previously referred to and advised members of the case of the doctor that charged the equivalent of R61,000 per hour. We also have examples of doctors charging between R19,000 and R33,000 per hour for the treatment of non-life threatening, non-emergency procedures. Consequently, if medical schemes are being forced to pay these high charges, then member contributions will in turn have to increase proportionately, resulting in members being forced out of private healthcare coverage due to unaffordability.

By having the option of a DSP, you as a member are now able to negotiate with your doctor, because unless you are willing to pay the difference between what your doctor wants to charge and the Genesis scale of benefits, you can choose to be treated at the DSP, in which case the claim will be reimbursed in full by Genesis.

The misconception that some members may have that they pay for private healthcare, but only have access to treatment in public hospitals, is unfounded.

Members of Genesis are not forced to seek treatment in a public hospital just because there is a DSP in their area. If, however, there is a DSP in your area and you choose to be treated for a PMB condition in a private hospital, then you will be liable for the difference between what the doctor charges and the Genesis scale of benefits.