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Tariff guide loss a blow for medical aids

Oct 27 2010 11:53
Johannesburg - The demise of the national health reference price list (NHRPL) presents "serious challenges" for medical schemes, Pro Sano Medical Scheme said on Wednesday.

With no valid guide on which to base their tariff structures, schemes had been left to come up with their own tariff and rates structures for the coming year, clinical operations executive Dr James Arens said in a statement.

The list is used by many medical schemes as a guideline to determine the rate at which they pay healthcare providers on their members' behalf.

"This is typically a complex and lengthy exercise which requires much research and extensive negotiation with service providers."

He said in terms of the Competition Act, the industry could not come together to determine recommended rates and tariffs as this would be viewed as collusion.

This followed the scrapping of the NHRPL by the High Court in Pretoria earlier this year, hampering the health department attempts to control prices in the private healthcare sector.

"Schemes also anticipate that certain providers may take advantage of the uncertainty around tariffs, charging exorbitant fees, especially for prescribed minimum benefits (PMBs), which by law, medical schemes are obliged to cover in full," Arens said.

Those likely to suffer most were the medical aid members themselves.

He advised members of medical aid schemes to be aware of the industry uncertainty around pricing and tariffs.

"In addition, when consulting a doctor or any other service provider, always make a habit of understanding what you have been charged for. "Monitor your claims statements closely and query any irregularities with your service provider."

Arens said members should make sure they knew upfront what portion of their accounts would be covered by medical aids and what amount would be for their own accounts.

Members also needed to get into the habit of negotiating discounts with their service providers to get more out of their benefits. Where possible, people should also look at using designated service providers, with whom their medical scheme had pre-negotiated discounts.
health insurance  |  medical aid


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