Making sense of...
Why do medical schemes contract with
specific networks of health care providers?
The main purpose of contracting network providers is to save Medical Scheme members money. Medical Schemes are non-profit entities and the ever-increasing medical inflation rate poses a challenge to these entities to keep health cover premiums affordable.
Medical Schemes do not have a lot to work with to achieve this and contracting with specific designated service providers (DSPs) is one way of decreasing healthcare delivery costs.
Medical Schemes will negotiate with networks of hospitals, doctors, specialists, and pharmacies to deliver services to their members at a lower rate.
The designated service providers (DSPs) benefit due to the medical schemes directing more of their members to use these service providers.
How does the use of DSPs benefit medical scheme members?
The contracting of designated service providers (DSPs) results in direct benefits for medical scheme members. In-network hospitals, doctors, or pharmacies agreed to not charge you more than the agreed-upon cost, resulting in:
- Preservation of your benefits covering day-to-day medical expenses
- Prevention of unexpected out-of-pocket payments
- Lower premiums for similar benefits on a medical scheme network benefit option
Find out if your medical scheme offers network options here
Making use of DSPs is a choice.
Medical Schemes do not force their members to make use of DSPs, you can choose to make use of any service provider of your choice, however, be aware that it can result in out-of-pocket payments.
If you want to prevent out-of-pocket payments and save, make sure you are informed and aware of the DSPs contracted by your Medical Scheme.
Does lower cost of health cover provided by DSPs mean lower quality of care?
Network providers have to adhere to the contracted quality of care and ensure Medical Scheme members receive comprehensive and optimal care within the specified clinical pathways like medicine formularies and reduced administration costs.
Medical Schemes utilise DSP agreements to save on costs across all the different benefit options. On some benefit options, it will only be applied to Prescribed Minimum Benefit (PMB) care or chronic medication providers and other benefit options will be linked to a specific network of private hospitals.
Understanding your Network Benefit Option is key – be informed
It is of vital importance to follow the correct processes when you are on a Medical Scheme Benefit Option that use a list of Network Hospitals. If you make use of another hospital or receive treatment from a specialist that is not part of the network, it will result in penalty co-payments. Important facts to keep in mind to prevent a penalty co-payment:
- You can only utilise specialist that operate in one of the hospitals on your network list.
- Some schemes require a referral from a network GP and then you need to get pre-authorisation before visiting the specialist for a consultation.
- Any further procedures done in a non-network hospital or by a non-network specialist will result in penalty co-payments, including a percentage of the hospital bill