Designated Service Providers (DSP)

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 on the MED-100 option is 100% of the scale of benefits.  On all other benefit options the rate of reimbursement is 200% of the scale of benefits.

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.