Medical aids in South Africa are essentially a health insurance. In the event that you need to access medical services, your medical aid will ensure that you have financial cover to meet your bills. Many practitioners, pharmacies and all private hospitals claim directly from your medical aid so as not to inconvenience you with up from cash payments.
Nevertheless the contract exists between you and your medical aid and any provider who is contracted into a medical and dealing directly with your scheme is actually doing you a favour.
In the ideal scenario, most medical providers would opt not to deal with a medical aid. Doctors, pharmacies and hospitals are business entities. Billing a medical aid involves administration costs, delays on the part of your medical aid and at times, there is no payment if your funds are exhausted. This is an additional expense for your provider.
However South African medical aid members do expect providers to deal directly with their medical aid either due to financial restrictions or an unwillingness to spend money for medical services. If you do not have the cash to pay for your medical services and wait for your medical aid to reimburse you, then you need to find a practitioner who is contracted into medical aids.
These days, many doctors are contracting out of medical aids due to inefficiency on the part of medical schemes, limited cover for services and fraudulent use of medical aid cards and identity documents. This puts the provider at risk of bad debts as patients are sometime untraceable or file for debt administration, meaning that the provider does not get their payment or may receive only a small portion of it.
Many providers are now charging ‘private’ rates or SAMA rates, which are higher than the NHRPL (National Health Reference Price List). Most medical aids only pay the NHRPL rates as these are set by the Department of Health in conjunction with the Council of Medical Schemes and health associations.
If your provider charges private rates, you medical aid will only pay the portion of that claim which meets with the NHRPL. In this case, any cash payment you make to the doctor will not be reimbursed to you in full by your medical aid. Many medical aids now offer hospital cover that will pay up to 300% of the NHRPL rate to ensure that you have full cover in the event of treatment by a doctor charging private rates for hospital visits and procedures.
Some medial aid members in South Africa still have difficulty in comprehending the way the system works. Having a medical aid is not a guarantee that you can consult with any doctor or purchase any drug with full cover from your medical aid. It is important to compare medical aid benefits at the outset so that you are aware of the restrictions and exclusions of your specific plan.
It is important to bear in mind that as a medical aid member, the contract exists between you and your medical – you are the medical aid’s client and they are your financial security for health costs. The doctor, pharmacy or hospital has no part in this contract although many of these providers deal directly with a medical aid to ensure convenience for the patient.