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06 July 2011

Why are designated service providers important?

A Designated Service Provider is a healthcare provider that is a medical scheme’s first choice when its members need diagnosis, treatment or care for a PMB condition.

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A Designated Service Provider (DSP) is a healthcare provider (doctor, pharmacist, hospital, etc) that is a medical scheme’s first choice when its members need diagnosis, treatment or care for a PMB condition.

If you choose not to use the DSP selected by your scheme, you may have to pay a portion of the bill as a co-payment. This could either be a percentage co-payment or the difference between the DSP’s tariff and that charged by the provider you went to.

Medical schemes have to ensure that it is easy for beneficiaries to get to the DSPs. If there is no DSP within reasonable distance of your work or home, then you can visit any provider and the scheme is obliged to pay.

When you suffer an emergency condition, or are involved in an accident, you may go to the nearest healthcare facility for treatment, even if it is not a DSP. Your scheme will have to cover the costs.

Schemes also have to ensure that the DSPs of their choice can deliver the services needed and without members having to wait unreasonably long. Where a DSP is unable to accommodate or treat a member, the medical scheme remains liable for all the costs of treating the PMB condition at a non-DSP.

The state’s healthcare facilities can be, but are not necessarily, DSPs. Before they can be listed as such, schemes have to make sure that their beneficiaries can get to the facilities and that the required treatment, medication and care are available and accessible. Many scheme members are unaware that the state hospitals are the DSPs for the treatment of certain conditions on particular medical scheme options.

Treatment at DSPs can be handled in two ways:

 Council for Medical Schemes

  • 1.) Schemes can insist that you go to a DSP as soon as your condition is diagnosed, in which case they cover the costs from the start. Treatment at a DSP will be covered in full by the medical scheme under the PMB conditions when delivered according to scheme protocols and formularies.
  • 2.) If your benefit option allows for this, you can be treated by the doctor of your choice. If you choose to use a provider of your choice for these services, the scheme may apply a co-payment, as registered in their rules.

(Health24, updated September 2010)

 
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