Genesis has Designated Service Provider (DSP) contracts with the Departments of Health in Gauteng, the Western Cape and the Northern Cape.
Some of our members may be under the impression that they have to go to a state hospital for treatment of a Prescribed Minimum Benefit (PMB) illness condition.
For those of you who have missed the notice, here is a link to the previous communication:
Are members now forced to use public hospitals for the treatment of PMBs?
NO – ABSOLUTELY NOT!
Genesis members can be treated for a PMB illness condition in any private hospital in South Africa. You do not have to go to a state hospital.
The question that follows is then why have DSPs?
The Registrar of Medical Schemes has directed medical schemes to pay all PMBs in full if treatment is obtained from a non-DSP. This is irrespective of cost, even if the doctor charges the equivalent of R60 000 per hour!! Clearly, medical scheme contributions will be completely unaffordable if all doctors charged this rate. Therefore, the only way to protect the members of Genesis from such doctors that charge these high rates is to offer members the choice of how they want their claims reimbursed.
What exactly does that mean?
It means simply that if the doctor that you consult to treat your PMB illness condition wishes to charge above the Genesis scale of benefits or tariff (“medical aid rate”), then you will be liable for the co-payment to settle the difference between the Scheme’s tariff and what the doctor charges. In other words, you have a choice of how you want your claims reimbursed – in full at a public hospital or at the Genesis tariff if you are treated by a private doctor.
Also bear in mind that the majority of doctors’ charges usually fall within the Genesis tariffs, which mean that your private hospital PMB treatment could be covered in full. Where possible, please find out from the doctor(s) that will be treating you as to what their charges will be, and / or request them to bill for their services in line with your medical scheme cover.
In short, the reason for selecting DSPs is to put a stop to those doctors that seek to exploit the “pay in full no matter how much the charge” directive of the Registrar of Medical Schemes. Only in this way can medical scheme contributions be kept at a sensible level for the benefit of all members.