Doctors and Therapists Contracted In and Out of Medical Aid

Being a member of a medical aid does not mean that you can access medical services from any provider without having to pay any cash fees. At times there is a misconception by medical aid members that a doctor or other medical service provider is forced to treat you and accept payment directly from the medical aid.

Any medical service provider in South Africa, whether a general practitioner, medical specialist, and auxilliary therapists like physiotherapists, psychologists, chiropractors and so on have the right to request cash payments for their services.

Contracted Into Medical Aid

Many general practitioners and auxilliary therapists as well as some medical specialists are contracted into medical aids. This means that the doctor will bill your medical aid for the service and will be paid directly by the medical scheme. Those practitioners that offer this service do so as a means to assist patients with the cost of medical care.

Patient’s are not inconvenienced by paying cash upfront and then claiming back from their medical aid. Instead the doctor’s administration staff will handle all matters regarding the submission of medical aid claims. At no time does this mean that your doctor is working for the medical aid. The contract is always between the medical aid and the member and the scheme is simply issuing the payment to the doctor since you have not paid for it in cash.

Handling medical aid claims and at times chasing payments from the medical aid is a costly and labour intensive affair on the part of your doctor. If there is a shortfall or your medical aid fails to pay the doctor, you are then liable for reimbursing the practice. You can always choose to pay your doctor in cash and claim back from your scheme even if your doctor is contracted into medical aids.

The cost of consultations, procedures and medication is decided upon by the Council of Medical Schemes and Department of Health and set out in the NHRPL (National Health Reference Price List). Your doctor can only charge¬† your medical aid according to the appropriate tariffs and will be reimbursed as indicated in the price list. You may be liable for a co-payment even if your doctor or therapist is contracted into medical aids. If you are not a network plan or your medical aid only pays designated/preferred service providers, then you will only be able to consult with designated doctors or therapists as per your medical aid’s approval.

Contracted Out of Medical Aid

More doctors are now contracting out of medical aids for various reasons. The cost of managing medical aid claims, coupled with late payments, reduced benefits and tariffs has led practitioners to charge cash upfront for their services. In this instance, the patient has to pay for the services in cash and then submit a claim to the medical aid for reimbursement. In order to claim back from your medical aid, your doctor will have to give you a statement with a 7-digit practice number, the appropriate tariff and ICD-10 codes.

While this may seem inconvenient and costly as you would need to pay your doctor before you receive reimbursement from your medical aid, you always have the choice of consulting with a practitioner who is contracted into medical aids. If you cannot find a practitioner who is contracted into medical aids in your area, then you should speak to your scheme about recommendations. Your general practitioner may also be able to refer you to a practitioner who does accept medical aid payments.

Doctors who are contracted out of medical aids may not necessarily charge NHRPL (National Health Reference Price List) tariffs. The doctor’s fees may be higher or lower than these tariffs. Your medical aid, however, will only reimburse you at the NHRPL rate or lower if your doctor charges you less than the tariff amount. Some medical aids do pay for hospital costs at a higher rate of up to 300% of NHRPL rates. At times, your medical aid may pay the member for the procedure and treatment although the doctor has submitted the claim. In this instance, the member of the medical aid is required to reimburse the doctor or possibly face legal action.