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What does “100% of Medical Aid Rate” mean?

Understand funding for hospital admissions (Part 2 of 3)

Have you read Part 1 of our series on this topic?

We discussed how hospital admissions and the payment of claims work, we looked at aspects such as authorisation numbers vs admission reference numbers, some important aspects pertaining to admission and discharge times and also how hospital and provider accounts are all separate and independent from each other.

In Part 2 of our series we will now elaborate on some of the most common reasons why members could end up with unpaid hospital and related bills.

Tariff shortfall(s)

Each benefit option stipulates the rate of cover at which Genesis will reimburse doctors’ / specialists’ (“providers”) claims, i.e. it will state that Genesis will reimburse claims at 100% or 200% of the Medical Aid Rate.

Remember what we said in Part 1 of this series – that provider accounts are separate and independent from your hospital account.  All providers run their own practices and don’t work for private hospitals.  Therefore, if your provider(s) charges 300% of the Medical Aid Rate, Genesis will only cover his / her claim(s) at 100% of the Medical Aid Rate if you are on the Private Choice option or, at 200% of the Medical Aid Rate if you are on the Private, Private Plus or Private Comprehensive benefit option.

In order to avoid co-payments on tariff shortfalls, discuss such charges with your provider (including your anesthetist) before you go to hospital.  Where possible, negotiate with him / her to charge you in line with what Genesis will cover.

Also be aware that your provider cannot charge you an inflated fee for an “emergency” if your admission / procedure is a planned event or if it is not a life threatening situation requiring “immediate” treatment.

Stated benefit shortfall(s)

Take careful note of any stated limits that may be applicable to your admission.  These include, but are not limited to the following examples (refer 2018 benefits):

  • Any internal medical / surgical prosthesis (e.g. hip / knee replacement, stent, pacemaker, etc.) has a limit of R30 000 per beneficiary per annum on all benefit options, except on Private Choice, which has a limit of 50% of cost up to R20 000 per beneficiary per annum.
  • Where possible, discuss the model and make of the prosthesis with your provider before the time to make sure he / she is aware of your prosthesis benefit limit. Very often, suppliers will negotiate the charge downwards.
  • External appliances (e.g. Taylor spatial frames / orthopedic fixators) used in the treatment of fractures under certain specific conditions, have a limit of 75% of the cost up to R18 000 per family per annum. Further to this, there are no in-hospital benefits for appliances such as crutches, moon boots, hearing aids, etc.)
  • A benefit limit of R3 000 per gastroscopy and R4 300 per colonoscopy is applicable on all options, except the Private Choice option, for which there is no scope benefit.
  • It is important to note that the above benefits are inclusive of ALL provider AND hospital fees. When done in hospital, the cost of these procedures may exceed the stated benefit, resulting in members often opting to have it done in providers’ rooms instead when the costs are very often much lower.
  • An in-hospital benefit limit of R10 000 is applicable for qualifying dental procedures (all benefit options). Due to the exorbitant cost related to hospital admissions, members often successfully make use of the more cost-effective alternative of intravenous sedation administered in the provider’s room.
  • A psychiatric benefit limit of R36 000 per beneficiary per annum may not necessarily cover 21 days’ stay in a registered health establishment. Always discuss these charges with your provider in order to avoid co-payments, or to find more cost-effective or alternative treatment options.

Benefits not provided for in your selected benefit option

Never assume that you are covered for “everything” in terms of your benefit option.  In addition to general exclusions (stipulated in Annexure C of the Rules), members are only entitled to the benefits as stipulated in their selected benefit options.  Members on the Private Choice option, for example, have no benefit for hemodialysis, epidural injections for conservative back / neck pain management or orthodontic services in a private hospital, as these benefits are not provided for in their selected benefit option.

Treatment not related to the primary diagnosis

Members and providers are often under the impression that all costs will be covered whilst they are in hospital, where in fact, this is not the case.  An example of this would be if you have your appendix removed  –   the Scheme will not pay for in-hospital psychiatric consultations, or dietetic services, or physiotherapy services just because you also suffer from depression, have high cholesterol or has a back problem.  In other words, you cannot have a general checkup just because you are in hospital and expect Genesis to pay.

Claims not in line with Doctor’s Billing Manual (DBM)

All claims are assessed in terms of the billing rules as set out in the DBM (published by the SA Medical Association).  Where more than one procedure is performed at the same time (e.g. where two cancerous skin lesions are removed from your thigh and back at the same time as when a hernia repair is performed), the DBM states that the surgeon may charge 100% for the first procedure, 75% for the second procedure, 50% for the third and 25% for subsequent procedures.

Providers often bill their fees outside the parameters stipulated in the DBM and then charge 100% for all three procedures, in which instance Genesis will apply what is referred to as “modifier 0005”.  The Scheme will therefore only reimburse claims as per the guidelines stipulated in the DBM.

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