Medical Aid Tariffs and Fair Value
December 6, 2024
Medical scheme rates are calculated for all of South Africa. Although some jurisdictions may feel the rates represent fair value, while others don’t. Let us delve further into the mechanics of medical aid tariffs as well as what encapsulates fair value.
The RBRVS technique is used in tabulating tariffs by medical schemes. A profile for claims risk is through combining available funds. The re-occurrence risk of the number of similar claims and looking back over prior periods to determine the processed number of total claims.
Understandable profit margins – Medical Aid Tariffs
They then use the results to set expenditures on affordability and not on actual medical practitioner costs. For appropriate health care deliverance. Using this methodology, the prices may allow for understandable profit margins. While covering the healthcare professional’s expenses, or it might not.
The agreement between patient and medical practitioner stipulates that it is the patient’s responsibility to make up any shortfall between their medical scheme’s payout and the real costs of treatment.
How you can determine fair value – Medical Aid Tariffs
For those feeling they did not get their fair value during their treatment. A recourse through a professional body is available to them via the Health Professions Act 56 of 1974:
A patient can, within three months of receiving the total actual bill, apply to the professional board. In writing, to decide what amount to settle their account regarding the services on the bill.
Following receipt of this application, the professional board, will, as speedily as possible, disclose to both the patient and the healthcare provider of the determined amount.
Before the professional board arriving at a final figure, it will allow the medical practitioner concerned time and opportunity to support their charges to the patient, in writing.
They balance fair value, not undercutting any side of the equation. Neither the service delivery end nor not the insurer end. Medical practices require viable levels of revenue generation, so as to sustain them.
It also helps them decide whether to accept tariffs set by various medical aid schemes to receive their payments through direct payments, under contract.
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All info was correct at time of publishing