What are medical scheme tariffs in South Africa?

December 9, 2021

In South Africa, medical boards set medical scheme tariffs for the whole country.

The idea is to provide a fair payment for the medical professionals and the patient.

Unfortunately, this is not always the case. What may seem fair to a doctor in one area may not be suitable to another elsewhere.

This is due to the differences in the cost of living.

Understanding how medical schemes work out their rates will help us understand what is a fair price.

Trying to make sense of Medical scheme tariffs

Medical scheme tariffs

Medical aid schemes use past statistics to help them determine the medical aid rates.

First, they look at how many claims there were over a particular period. Then they try to determine how likely it is the claims will recur, and what funds they have.

This enables them to draw up a risk profile. It is from this that they derive the medical aid rates. The profile determines what they will pay rather than what the cost is to your doctor.

In some cases, this may allow for the doctor to make a decent profit  In others, it will not. In those cases, where there is a discrepancy, the patient will be responsible for the difference.

Medical scheme tariffs – Am I being treated fairly?

So, how do you make sure that you are being treated fairly or not? This is difficult. After all, what you think is fair may be looked at very differently by the doctor.

You have the choice to complain to the medical board if you feel that you were unfairly treated. The board will then allow the doctor a chance to defend his/her case. And then decide as to whether or not the charges were fair.

Unfortunately, it is something that is fairly vague. Medical practices are, after all, businesses just like any other. They need to work profitably or they are out of business.

This means that any shortfall will be borne by the patient. Whether or not the markup made by the doctor is fair will depend on their particular field of expertise and how skilled they are.

Medical aid schemes are a complex web of procedures

Those in the healthcare profession need to have extremely accurate accounting systems. This to ensure that they offer fair value and run a profitable business.

They take into consideration their own expenses and desired profit margins. Only then they make the decision about whether or not medical aid rates are acceptable to them.

Contracting directly with the medical aid scheme can be beneficial to their practices from the patient’s perspective. The patient will not have to pay anything upfront when visiting the doctor.

It could, however, also mean a delay in the settlement due to the fact medical aid pay claims at a set time rather than straight away.

The decision on what to charge lies with the medical practitioner and the decision to accept those charges lies with the patient.

Market forces should prevail to even things out.

To get a FREE single medical gap cover quote, just complete and send the form on this page

All info was correct at time of publishing