What happens if you use a non-DSP?
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DSPs are healthcare providers, including hospitals, doctors and pharmacies, contracted within your scheme as preferred service providers with the agreement to charge agreed rates for services.
Members of the scheme have access to medical care that is fully covered, while healthcare providers benefit from increased patient volumes, says Singleton.
DSP networks also extend to out of hospital treatment or care at pharmacies for chronic medication, where members need to use specific pharmacies to obtain medication for registered chronic conditions, he says. Members can be penalised financially for obtaining formulary chronic medication from a non-DSP pharmacy. By making use of DSPs you can avoid medical expense shortfalls for PMB conditions and avoid significant penalties and co-payments for treatment and medication.
There are certain specific instances where your medical scheme will fund the use of a non-DSP in full for PMB conditions, as regulated and required by the Medical Schemes Act, says Singleton. For example, if a DSP is not available to assist within a reasonable time frame, such as if a patient requires a heart bypass in hospital and the DSP (that is, the cardiologist) for the medical scheme is away, a non-DSP will be covered due to the urgency of treatment required.
The Act also states that if immediate medical or surgical treatment for a PMB condition is required under circumstances or at locations where the beneficiary cannot obtain treatment from a DSP, this will be covered. Also, if there is no DSP within reasonable proximity to the beneficiary’s ordinary place of business or personal residence then a PMB will be covered in full at a non-DSP, says Singleton.
It is important to remember that once your condition has stabilised or a DSP becomes available, your medical scheme may request you to use a DSP for further treatment.
When you require a medical procedure, you may do all of the required work to ensure you make use of a DSP specialist at a DSP hospital only to find on the day of surgery, for example, the anaesthetist preferred by your surgeon is not a DSP. This means that you will be liable for the medical expense shortfall for this doctor. Gap cover can help minimise this additional medical expense shortfall, says Singleton.
For a non-PMB condition, a non-DSP can incur significant penalties. Most specialists charge above the scheme rate and without gap cover you will have to pay the medical expense shortfalls not covered out of your own pocket.