Source: Johan van Tonder
Often you hear the complaint; "I'm paying way too much for medical cover". Often you hear people exclaim that they will never buy into the exploit medical scheme cover has become, as there is simply no value for money to be had.
Let me prove this wrong...
1. Get to know what your medical scheme cover offers:
People too often sign for medical scheme cover without taking the responsibility to know exactly what it is they are buying.
Are you opting for comprehensive (expensive) medical scheme cover that will pay your hospital expenses as well as day-to-day cover, or are you paying for a (cheaper) hospital plan that will take care of in-hospital expenses only? Often, the option you choose will offer a medical savings account that will take care of day-to-day expenses for as much as you have available in your savings account.
Too often members will expect too much from their medical scheme, thinking they are entitled to cover when indeed they have opted for a measure of self-insurance that does not quite cover their immediate needs.
Question: do you need comprehensive medical scheme cover? Consider your health profile – does anyone in your immediate yet extended family suffer from hereditary chronic diseases such as high blood pressure, high cholesterol or diabetes? This may concern your grandparents, parents, uncles, aunts, or siblings. Unbeknown to you, you may have the propensity to develop a chronic disease – something you need to plan for carefully. If the answer to this question is a resounding No! – why opt for the more expensive, more comprehensive medical scheme cover when a hospital plan may be all you need?
Question: do you need cover at more than the recommended tariff? Government determines a National Health Reference Price List (NHRPL) which acts as a guide to what practitioners or facilities such as hospitals should charge for services rendered. The reality, however, is that on average, practitioners charge up to 300% more than this guideline tariff. The question you need to consider is whether you are prepared to negotiate upfront with the practitioner about the fee being charged, or whether you would be prepared to pay the inflated fee charged? If you are prepared to haggle, settle for a scheme that will only pay the recommended fee. If not, choose a scheme that offers reimbursement at a higher rate.
However, lately medical schemes have come to realise that paying the increased fee puts them at a disadvantage, and fewer medical schemes are offering cover at inflated reimbursement rates. Instead, medical schemes offer guaranteed payment rates only if members consult with contracted practitioners who guarantee to charge a guaranteed price. Consider whether you are prepared to limit your choice of practitioners to the list of contracted practitioners to ensure guaranteed charges, or whether you want to dock up for freedom of choice?
2. Get to know your rights:
Medical schemes have to pay for both the diagnostic treatment and care cost of a number of conditions referred to as prescribed minimum benefits (PMBs). These PMB conditions refer mostly to a number of lifestyle diseases such as high blood pressure, high cholesterol, diabetes and the likes. There is a list of 26 conditions listed on the Council for Medical Schemes website that medical schemes have to cover in full. Medical schemes may mitigate their liability by imposing designated service suppliers such as a network of practitioners or a limited formulary of medicines, but the fact remains that members will enjoy full cover for these conditions, irrespective of the option they choose, providing they do their homework well
However, it would pay you to enquire from your practitioner whether the condition you have been diagnosed with is listed as a PMB condition, and if so, whether the correct procedure codes and ICD 10 codes were used in the billing process to ensure that the scheme will accept full liability and payment for the cost involved.
The Regulations as stipulated by the Medical Schemes Act 131 of 1998 and amendments, especially those in respect of fees payable for Prescribed Minimum Benefits and Chronic Disease List of 1 January 2004 (refer Chapter 3, paragraph 8, Sections 1 and 2; where it stipulates that any benefits offered by a practitioner in respect of any of these), Medical Schemes must reimburse IN FULL AND WITHOUT CO-PAYMENTS OR THE USE OF DEDUCTIBLES THE DIAGNOSTIC TREATMENT AND CARE COST of said prescribed minimum condition specified in Annexure A.
The onus remains with the member, however, to ensure that the condition is correctly listed and the codes used in the claim are correctly reflecting the PMB procedure and ICD 10 codes.