Here's what a healthcare broker should be doing to earn his/her keep. If yours isn't doing it, it might be the time to look for someone who will.
Scheme selection. Whether you are an individual or a corporate client, a regular review of your medical scheme arrangements is essential. Your needs will change and schemes usually alter their design and benefits on a yearly basis. A review of your situation should take place on an annual basis or whenever you have a life-changing event such as the birth of a child. This should be done using a detailed needs analysis to determine any health conditions or changes that you may have experienced.
Low cost involved. Currently medical schemes are not allowed to pay more than 3% (capped at R60.70) of your premium to your healthcare broker. If one compares this to any other form of professional advice, it is very inexpensive and having access to a healthcare broker may well save you many thousands of Rands over the longer term. Payment of this fee will not affect your premium in any way and therefore this service is effectively ‘free’ to you.
Independent advice. Many healthcare brokers operate independently of the medical schemes and most will be able to offer you a selection of at least three schemes (if they can't, then you should seek the advice of another broker). Many schemes market themselves via call centres and then do not offer you truly independent advice.
Guidance and explanation. Ever tried to fully understand your medical scheme? If like most people, you find the terminology and explanations confusing, then you need someone who can explain these aspects to you in simple and understandable layman’s terms. It often happens that members fail to claim as a result of not understanding the complex terms and phrases used.
Problem-solving. While many scheme call centers are efficient at taking your call, they are often manned by younger staff who, while they may understand the scheme benefits, have limited experience in the field of health. With every good intention in the world, they might not have a full understanding of what the scheme is legally obliged to pay for. A good healthcare broker will know the Medical Schemes Act, as well as the processes and procedures followed within the medical scheme and will thereforeus be in a position to ensure that your claim queries are handled efficiently and effectively.
Disputes. A healthcare broker has an obligation to take up any dispute you may have with the scheme. The healthcare broker will know how to address this within the scheme in order to obtain the best outcome. If this cannot be achieved, the healthcare broker can also advise on the legal aspects and complaints procedure as set out in the Medical Schemes Act.
An early warning system. The South African medical scheme market is extremely dynamic. Many changes are taking place and schemes are under increasing financial pressure. Besides the risk of closure or curatorship as seen recently on some schemes, many schemes are involved in merger talks. These mergers are increasing and may not be in your personal best interest. A good health-care broker monitors the year-on-year performance of the various medical schemes and monitors mergers. The healthcare broker will be able to guide you timeously if your scheme is under severe financial pressure and help you to change your scheme to a more sustainable one if required.
Your longer term interest. With the advent of many products that market and purport to do the business of a medical scheme, one can easily be misled into thinking that one has purchased a medical scheme. While at face value these products appear to offer adequate cover, there are often pitfalls and complications when one tries to claim. One could also be at risk later in life when one tries to join medical schemes that are registered under the Medical Schemes Act. This risk could include higher contributions due to late joiner penalties, waiting periods and exclusions.
Health as a priority. A good healthcare broker will focus on your health needs. It is a sad fact that there are many brokers in the market who will attempt to sell you a medical scheme with the sole intention of establishing a relationship with you and then trying to market the more lucrative and higher commissioned life and endowment products. In marketing circles this is known as ‘Bait and Switch’ (in other words sell you a product and then sell you other products – ever seen this happen with cellphone offerings?) and is often used aggressively by brokers who claim to be registered healthcare specialists.
A changing environment. We have already alluded to the fact that the healthcare industry is under constant change. One only has to view the manifestos of political parties to realise that many changes are afoot. To keep abreast of these changes will be virtually impossible for the layman and having a player on your side will ensure that no matter what transpires, your healthcare interest will be a priority and you will be well-placed to adapt to the changing environment.
(Victor Crouser for Health24, May 2009)