Medical scheme networks can save you if you follow the rules

You can save a lot in contributions by choosing a medical scheme option that limits cover to certain networks of hospitals, doctors or other healthcare providers, as long as you are sure you know the scheme rules and are prepared to use these providers.

Failing to use the network providers may cost you in unpaid claims or co-payments but using them should save you in contributions and out-of-pocket payments.

Cheap medical scheme options typically provide benefits mostly through networks, limiting your choice of general practitioner (GP), pharmacy, specialists and hospitals.

More affordable middle-of-the-range scheme options may also use certain networks and you may have the choice within an option to choose your own provider or use network providers. The network choice is known as an efficiency discounted option.

The Government Employees Medical Scheme, for example, offers its members the free-choice Emerald option or Emerald Value option that limits members to a network of hospitals. Selecting the Value option can save you more than R1 100 a month as a couple and more if you are a bigger family.

Networks for PMBs

Even if you choose an option that allows you a choice of doctors and hospitals, be aware that many schemes appoint networks of designated service providers (DSPs) for prescribed minimum benefits (PMBs) – the benefits that all schemes must provide.

Craig Comrie, chairperson of the Health Funders Association, says it is challenging for schemes to negotiate better rates for PMBs as these must be covered in full and at cost. Appointing DSPs is one of the few ways in which medical schemes can contain these costs and keep cover more affordable, he says.

Denied claims and disputes

Failing to use the specified network for PMBs or the specified benefits on a network option can result in denied claims or claims not paid in full.

Research done on complaints about DSPs in 2018 and released earlier this year by the Council for Medical Schemes, as well as it’s work on pre-authorisation and their annual report, identify the following areas as ones leading to lots of complaints:

• Poor communication

The Council for Medical Schemes says some schemes communicate poorly about the need to use a network provider, and they provide incorrect information about providers.

Regardless of who refers you, it is up to you as a member to check with your medical scheme whether any provider is within the network.

If your scheme’s list of providers is online, confirm with your scheme any provider you select is still contracted and ask the provider to confirm that they will charge your medical scheme’s rates.

If you decide to use a non-network provider for any reason, make sure you appreciate just how much more than the scheme rate you will be charged.

• Lack of availability of DSPs

The Council for Medical Schemes found members often use non-DSPs when the network provider is not located within a reasonable distance.

David Green, managing director of MedClaim Assist, a company that assists members with unpaid claims, says his impression is that a minority of members ask their schemes to tell them which doctors are in the scheme’s network. They are then often referred to providers who are far away from their home, operate at a hospital that is not convenient or who cannot perform the surgery for many months.

The Medical Schemes Act regulations stipulate that any DSP a scheme names must be within a reasonable proximity to where you live or work and available within a reasonable period.

• Difficulty finding specialists

Problems arise when members use a network hospital for a procedure performed by a specialist surgeon or anaesthetist who has not agreed to charge scheme rates.

At a Council for Medical Schemes webinar on pre-authorisation earlier this year, Mumsy Mashilo, the senior manager of complaints adjudication, said the council has received complaints about unpaid specialists’ costs when there were no DSP specialists at the scheme’s appointed DSP hospital.

The shortage of specialists and difficulty that schemes have contracting with them was highlighted by the Competition Commission’s Health Market Inquiry.

However, Comrie says some larger schemes do offer specialist networks and report that over 90 percent of specialist consultations take place within the network.

Using a surgeon or other specialist who is not within your scheme’s network can result in you incurring many thousands of rands of out-of-pocket medical bills.

On a hip replacement, for example, you could face a gap of R30 000 to R40 000 for the orthopaedic surgeon and anaesthetists, Green says.

If there is no DSP specialist at the network hospital, the scheme should pay the doctor’s costs in full, he says.

Green says the use of anaesthetists is typically not voluntary as surgeons choose the anaesthetist and members only meet the anaesthetist shortly before a procedure.

Medical schemes are often unwilling or unable to identify their DSP anaesthetists, creating a strong suspicion that schemes either have no or very few contracts with anaesthetists, he says.

• Short payment of accounts

The Council for Medical Schemes analysis of complaints identified that even when members use DSPs, PMB accounts may be short paid because the treatment exceeds the level of care covered for that PMB.  

It says this often occurs when members have had hip replacement surgery, cataract removal, emergency eye operations and urgent vascular surgery.

Network providers should be aware what the scheme covers, but to protect yourself ask the doctor to give you a list of procedure codes and check with your scheme that you are covered in full for those before you have a procedure or treatment.

Green says a good example is when a member needs a prosthesis which is supplied and billed for by the hospital.

However, your scheme may have a benefit limit for prostheses that results in short payment despite you having received authorisation for the hospital admission and procedure.

In its latest annual report, the council says if a prosthesis is required for a PMB condition, schemes need to consider the member’s needs and the cost of the device, not just the limit.

Green also says members should check the reason for unpaid or short-paid claims on the medical scheme statements. Rejected claim items with the code 328 as a reason indicates that the charges exceed the agreed rate and members are not obliged to pay these.

• Co-payments for the use of non-DSPs

Scheme options making use of networks are entitled to impose co-payments if you do not use the DSP or a network provider, unless you used a non-network provider in an emergency.

The Council for Medical Schemes says disputes arise about what constitutes an emergency.

Green says when a member sees a GP who advises them to go to the nearest hospital which is not in the network, the scheme may argue that the member chose voluntarily not to use the DSP.

And in other cases where the admission is recognised as an emergency, the scheme expects that after 24 hours of care, the member should have been stabilised and transferred to the DSP hospital, he says.

But often it is not clinically appropriate for a member on life support or in intensive care to be transferred, Green says. 

Be persistent

Although you need to follow the rules and use your scheme’s appointed providers, Green says many schemes do not pay claims properly and use jargon when a member ask for reasons. This often results in members giving up. 

To get your scheme to pay properly, you need to persevere and know what you are talking about, he says.