Some medical schemes have network doctors and hospitals or designated service providers (DSP), where members won’t have to pay a contribution to the medical expense, within reason. However, if you choose to visit a non-network hospital or doctor, you may be required to pay all or part of the costs. This not only applies to doctors and specialists, but to other medical professionals such as dentists and optometrists as well.
When making an appointment with a medical professional, first ask if they charge medical aid rates. If they do not, you will most likely have to pay the difference, this is usually called the member contribution. If they do charge medical aid rates, your medical provider will generally pay the doctor, unless network providers are applicable and the medical professional you are visiting is not on the provider list.
In addition, you should also ask if they are affiliated with any medical scheme and if they will submit the claim to your medical aid scheme. There are also instances where doctors and other medical professionals will require you to pay the consultation fee upfront, and you will then be required to submit a claim to your medical aid provider for reimbursement.
Designated service providers
The use of DSPs by medical aids helps to keep the cost of treatment down and reduces the need for member contributions. Bestmed explained: “Making use of DSPs will ensure that claims are paid in full. Exceptions are made in case of emergencies, where no DSP is available or where a member cannot be accommodated within reasonable time. Members have the choice to voluntarily use non-network providers, however, they may be charged with higher fees or co-payments for the member’s own account.”
Discovery Health Medical Scheme also has agreements with healthcare professionals to help bring down the cost of consultations and treatment. “We enter into agreements with healthcare professionals to ensure certainty of cover for our members and higher levels of reimbursement for healthcare professionals who we pay in full. Our agreements cover 90% of GP and specialists visits respectively.”
For both Bestmed and Discovery, members can find lists of the DSPs when they log into their profiles on the medical schemes’ websites. And they are not the only medical schemes to have DSPs. The Medshield website provides a list of healthcare professionals that the medical aid has partnerships with.
However, if you don’t have access to the internet, you can always phone your medical aid provider and ask for the nearest DSP or network provider in your area. For some of the medical aids, the different options offer access to different DSPs, as the number of specialists and doctors available to you may be dependent on the scheme option you chose. The higher the option, the more doctors you will have access to.
Gap cover
To help cover expenses that your medical aid may not pay or that they will only pay a portion of, there is gap cover. Sanlam noted that gap cover “provides for the difference between what your medical aid pays and the rates charged by medical specialists.
“In certain cases the cost for in-hospital procedures or outpatient treatment may exceed the base medical aid rate by 5-times,” added Sanlam.
