Medical boards in South African set medical scheme tariffs for the whole country.
The inspiration is to provide fair payment for medical professionals and patients.
However, this is not always the case. What may appear appropriate one doctor in a given region may seem unfair to another doctor in another area.
We can attribute such disparities to differences in the cost of living in different regions.
Therefore, understanding how medical schemes work out their rates will help us understand the concept of fair price.
All About Medical Scheme Tariffs in SA
Trying to make sense of medical plan tariffs
Medical aid schemes make use of previous data to determine medical aid rates.
First, they have a look at the number of claims reported during a given time. Then they try to calculate the probability of claims recurring and the funds they have.
Such calculations help in drawing up a risk profile, and it is from this they can derive medical aid rates. The profile determines what they will pay and not what the doctors are likely to charge.
In some cases, doctors can make a profit, and in some cases, they cause loss. In the case where there is a difference between the two, patients’ make up for the gap.
Medical scheme tariffs, Am I being treated fairly?
How do you make sure that the medical scheme will treat you fairly? That is a difficult task since what you think is fair, and doctors could be having a different perspective.
It is always within your right to make a complaint to the medical board whenever you feel that they treat you unfairly. The board allows the doctor to make a defense before making a decision whether the charges were fair or not.
Since medical practices have become businesses just like any other business, and need to make profits, they require patients to make up for any shortfalls.
Medical Aid Schemes are a Sophisticated Web of procedures
Professionals operating the Medical sector need to have an accurate accounting system. This system ensures that they offer value for money services and at the same time run a profitable business.
As such, they take into consideration their expenses and desired margins. It is only after making such calculations can medical professionals make a decision whether creation medical rates are acceptable to them.
Making a choice to contract directly with the medical aid scheme can be beneficial to their practice from a patient’s perspective since they will not pay a penny when visiting a doctor.
However, this could translate to delays in the settlement because medical aid pay claims set a time frame rather than upfront payments.
However, the decision on what to charge lie with the medical professional and the decision to accept the charges lies with the patient.
Get a FREE gap cover quote by entering your details into the form provided and clicking the GET A QUOTE button!
All info was correct at time of publishing