1. Use your medical scheme’s preferred network provider.
Medical schemes have agreements in place with carefully selected provider groups and individual providers, these include, but are not limited to hospitals, doctors, dentists and pharmacies. Specific rates and preferred actions, such as formulary prescribing, are negotiated to limit out of pocket expenses for scheme members.
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2. Compare quotes before having a procedure.
Every medical scheme has a rate of payment called the Scheme Rate. It is the amount the scheme will pay for specific treatments and procedures.
Please note that approval at 100% of the Scheme Rate doesn’t necessarily mean payment at 100% of the account or what is being charged.. Be sure to confirm that your provider is on the network or is willing to charge the Scheme Rate to avoid costly co-payments. They will be able to advise if they charge the Scheme Rate or more. They can also provide you with a quote for their services which your medical scheme can check against the Scheme Rates. Remember that you can negotiate discounted rates with providers.
3. Check your hospital accounts.
Please do not hesitate to contact your medical scheme if you have any questions about short payments on your hospital accounts. The scheme will assist as far as possible to resolve short payment queries. It may be that the scheme has not received all the information needed from the hospital to cover certain costs. Your medical scheme will be able to offer guidance in this regard.
4. Use generic and formulary medicine.
Generic medicine meets the same rigorous safety standards as the original branded medication and is approved by the South African Health Products Regulatory Authority (SAHPRA). Generic medicine is often significantly more cost effective and can help you prevent out of pocket expenses. Always ask your pharmacist for a cost effective generic alternative. Medicine formularies are carefully selected to include safe and cost effective medicine. If your medical scheme applies a formulary to medicine benefits, please ask your doctor to prescribe according to the formulary. This will ensure you have access to effective medicine that is covered in full by your medical scheme.
Please note that any change in chronic medicine should also be communicated to your medical scheme to ensure your authorisation is updated.
5. Avoid non-emergency after-hour consultations.
Where there is a valid emergency, you may have no choice. But where there are minor complaints that can wait, rather avoid visiting the GP at the 24-hour clinic on a Sunday morning. It is going to cost you significantly more than it would on Monday morning. This is due to additional fees charged by the GP and possible hospital facility fees if the GP is based in a hospital emergency room. You can access after-hours virtual consultations via Hello Doctor.
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