Medical Aid GP-Specialist Referral System

As medical aids in South Africa tighten their belts, many new policies will be implemented that may upset some of its members. The GP-specialist referral system is one of those policies as many medical aids now restrict their members from visiting a medical specialist directly without a referral from their GP. Despite objections from medical aid members, many schemes are forced to implement this system not only for monetary reasons but also to offer the patient a complete managed healthcare service.

Medical Shoppers

The reality is that a proportion of medical aid members are medical ‘shoppers’. They visit their GP for an ailment and if it does not resolve with the initial treatment then they hop over to another GP or specialist. Conveniently these patients do not divulge their full medical history to the attending doctor so successive practitioners are unaware of previous prescriptions, tests and procedures. This often leads to repetition by each doctor and ultimately wastes the patient’s medical aid resources.

Specialists Better than GP’s

Another growing problem is that many South Africans believe that a medical specialist is better than a general practitioner. They tend to bypass the preliminary stage (GP evaluation) and consult with a medical specialist directly. This just adds on costs of more specialized practitioners dealing with everyday ailments that may not be related to their field of specialty. Unfortunately most medical aid members do not appreciate the difference and view their membership as an unlimited ‘credit card’ where they can spend all year long.

Managed Healthcare

The concept of managed healthcare is quite broad but basically intends to coordinate the access and financing of medical services through greater communication among service providers, patients and the medical aid. Unfortunately service providers do not often communicate with each other, just as patients do not communicate with their service provider. This leaves the role of managed healthcare to the medical aid, where the services, drugs, procedures and investigations can be monitored and wastage of funds reduced.

So what does this mean for you?

If your medical has implemented a new policy stating that you can only visit a specialist if your GP deems it necessary, then you have to follow that procedure. Your medical aid is trying to save you money and prevent your benefits from getting exhausted early in the year. Hopefully your GP will look after your interests as well and refer you to a specialist when necessary.

Currently, these type of policies do not apply to higher plans on most medical aids. But declining membership numbers as more patients switch over to closed medical aids, higher payout costs due to the HIV infection rate and the rising cost of healthcare in South Africa may see new systems being adopted by medical aids. The GP-specialist referral system is just one step to controlling unnecessary spending but it is not the last.

Remember that if you medical has instituted this system, it is your responsibility to get a referral note or number from your GP. Failure to do so will mean that the specialist will not be paid by your medical and you will be responsible for the bill. If your specialist is contracted out of medical aid, you will not be reimbursed for the cost of the specialist services without the GP referral.