Nobody wants to sit with huge co-payments or unexpected out-of-pocket expenses after a hospital admission.
There is often uncertainty and / or misperception about the liability of a medical scheme to settle claims. It is therefore imperative for members of medical aid schemes in South Africa to familiarise themselves with the benefits and limits of their selected plans. Understanding the terms and conditions that may be applicable is of equal importance.
In this first series of 2 articles on the subject we will discuss some important aspects around the use of Designated Service Providers (“DSPs”) and private doctors’ fees.
Designated Service Providers
Understanding how scheme funding works is of particular importance as far as the treatment of Prescribed Minimum Benefits (“PMBs”) and DSPs are concerned.
Generally speaking, a DSP refers to a healthcare provider(s) selected by a scheme as a preferred provider(s) for the diagnosis, treatment and care for PMB conditions, or benefits in general.
Are members forced to use DSPs?
The selection of DSPs in no way forces any member to seek treatment in a public hospital.
When Genesis members make use of a DSP for the diagnosis, treatment and care of a PMB condition, the Scheme will usually reimburse those claims in full. Furthermore, the treatment they receive must be the same treatment that is available to any patient that does not have medical aid. This is referred to “PMB level of care”.
Despite the Scheme’s selection of DSPs, members have the privilege of being treated in any private hospital.
If members voluntarily choose to be treated in a private hospital, then the claims will be subject (and may be limited) to the benefits available on their selected benefit option. This scenario is applicable even if the illness / condition is listed as a PMB. Members may therefore be liable for co-payments (difference in cost) that may arise if their doctor(s) charges more than the Scheme Rate.
Members’ doctor / specialist claims on the Private Choice option will be reimbursed at 100% of the Scheme Rate. Members’ cover for doctors / specialists on the Private and Private Comprehensive options is at 200% of the Scheme Rate.
Understanding private doctors’ rates
Unlike the public sector, private practicing doctors are not employed by private hospitals. This means that during a typical hospital admission involving surgery, separate claims will be submitted. Claims can be from the hospital, the treating surgeon, an assistant surgeon, the anesthetist, the radiographer, the pathologist, the pharmacist, possibly physiotherapists, etc.
Each healthcare service provider that treats you in hospital is an independent profit centre. They run their own business for profit. When they charge more than the benefits and / or the Scheme Tariff that you are entitled to in terms of the Scheme Rules, it will be for your own account.
For planned procedures, always speak to your doctor before going to hospital. Ask him / her for a quote for your procedure and then discuss it with the Scheme. If he / she charges more than what Genesis will cover i.t.o. your selected benefit option, then negotiate the fees charged by him / her.
Our next article will focus on other important aspects to consider in order to avoid or minimise potential co-payments after a hospital admission.