There's a misconception that providers are on medical schemes' networks because they cannot find enough business.
But Jeremy Yatt, the principal officer of Fedhealth, says this is definitely not the case. "Contrary to popular belief, network providers help us to offer quality health care and provide schemes with data to ensure they adhere to best practice."
Networks are one of the key ways that schemes protect themselves against the rising costs of health care. If schemes didn't contain these costs, schemes would have to hike your contributions significantly or slash your benefits. A good medical scheme will always ensure that it contracts with practitioners who can provide you with quality care.
You need to know when you should use a network if you want your scheme to pay your claim, or if you want to avoid a co-payment.
Here are the types of networks that your medical scheme may use:
1. Designated service providers for the prescribed minimum benefits
A scheme may appoint a designated service provider (DSP) that you must use to be covered for a prescribed minimum benefit (PMB). The PMBs cover all medical emergencies, a list of conditions that are life-threatening or that can seriously affect your quality of life, as well as 25 common chronic conditions.
A DSP is a provider, or group of providers, chosen by the scheme to diagnose and treat PMB conditions. If a scheme has appointed a DSP and members use a non-DSP for a PMB service, the scheme may impose a co-payment or deductible. But if you obtain a PMB service from a non-DSP involuntarily - for example, in an emergency - a scheme may not impose a co-payment or deductible.
2. Designated providers for non-PMBs
Medical schemes typically offer cheaper contributions for options that use provider networks. If you don't use the healthcare providers on these options, you will face a co-payment, or your treatment will not be covered at all.
Typically, a scheme will contract with a hospital group, a network of general practitioners (GPs) or a primary healthcare network. Schemes may also offer certain benefits, such as oncology, through a network. On Fedhealth's options, members who visit a doctor within the scheme's GP network will have their consultation paid for by the scheme, rather than from their medical savings account.
3. Preferred providers
A medical scheme may set up a network of preferred healthcare providers. Unlike a DSP, members don't have to use a preferred provider, but if they do, they will be charged preferential rates and/or in the case of benefits paid for by the scheme, their treatment will covered in full.
Schemes often set up preferred-provider networks of specialists. These specialists agree to charge at the scheme's rate, so they are assured that the scheme will cover your bill in full. The incentive for specialists to agree to charge the scheme's rate is that the scheme agrees to pay them directly, which reduces their risk of bad debt.
4. Efficiency-discounted options
Efficiency-discounted options (EDOs) are sub-options of medical scheme options. These sub-options are designed around your willingness to limit your choice of provider. A healthy person, for example, might agree to use the public healthcare sector for chronic care, because he or she is unlikely to need this benefit.
Members of EDOs agree to pay lower contributions in return for having their choices restricted when they are treated for all medical procedures, not just the PMBs. The scheme may also demand a co-payment for certain elective procedures.
5. Capitation options
When a scheme sets up a capitated option it enters into an arrangement with a healthcare provider where it agrees to pay the provider a pre-negotiated fixed fee per member in return for the provider supplying its members with certain medical services.
The set fee remains the same regardless of how many times you see the doctor, dentist or other healthcare provider contracted to service you. Most capitated options have networks for day-to-day healthcare benefits and control the costs of hospital benefits through hospital networks or limits on benefits.
Please visit: www.fedhealth.co.za