To obtain optimal value from your medical scheme plan, it’s critical to fully understand the scope of benefits it offers and to manage those prudently. It’s an especially important consideration during the winter months. This is according to Dr James Arens, clinical operations executive at Pro Sano medical scheme.
Minor ailments like a recurrent common cold, for example, may not necessarily require repeated doctor visits that could potentially use up benefits that might be more appropriately used elsewhere.
Dr Arens points out that the economic climate in recent years has seen many South Africans downscaling on their lifestyles.
“This often means ‘buying down’ when it comes to medical scheme cover. It’s understandable that when money is scarce, people wish to pay as little as possible while still deriving maximum benefit. Hands-on active involvement by the member is very important in achieving this and all the more so if the plan is a low-cost one with limited benefits.”
Dr Arens suggest some strategies that can assist in this regard:
GP visits and medicine purchases for common winter ailments like colds and influenza are usually paid for from medical savings accounts, which can easily become depleted if the entire family get ill, sometimes repeatedly, during winter. “A common-sense approach is to keep unexpired medicines in a safe cupboard. For example, where it’s clear that your younger children have caught the same cold your elder child had last week, call your GP about the symptoms and tell him what medicines you have on hand, before scheduling unnecessary additional consultations. Most doctors are happy to discuss such matters with their patients and recommend which medicines to take.”
Vulnerable individuals, such as children, the elderly and those with pre-existing chronic conditions like diabetes, may suffer more serious winter illnesses, such as bronchitis or pneumonia, which can be complications of colds and influenza. “If your GP refers you to a specialist, take all your X-rays and tests along, remember that they are your property. If you’ve had tests done recently, inform or remind your doctor before agreeing to more tests that may not be necessary. You are also entitled to all your clinical records and should share these if you change doctors, as this information can obviate the need for further tests and even reduce the number of required consultations.”
When it comes to hospitalisation and expensive procedures, it is usually mandatory that members get formal authorisation. “While it’s common for a doctor to do this on a patient’s behalf, I strongly urge members to call in personally. This will ensure that they get first-hand information on any disclaimers and exclusions.”
Dr Arens advises that when consulting a doctor the member should know which benefit their claim will be paid from. “Review and monitor your claims statements closely and report any irregularities to the scheme. Schemes are not always in a position to determine exactly what transpired in the consulting room or hospital, so members need to play this monitoring role”
Lastly, to paraphrase the old adage, prevention is cheaper than cure. “Simply having the relevant influenza vaccinations can potentially reduce your seasonal health expenditure dramatically,” Dr Arens concludes.
(Issued on behalf of Pro Sano, June 2011)