05 October 2010

Maximising medical scheme benefits

Medical scheme benefits: can members manage and maximise them to last longer?


The economic climate has started to affect South Africans in all aspects of their lives. In order to cope, a lot of people are generally keeping a strict check on their expenditure as well as downscaling on some luxury lifestyle habits.

Medical scheme cover is one of the items in which some people have been buying down to lower options. Some people’s health status may be such that they cannot be adequately covered on lower options, and instead may require enhanced benefits. When money is scarce, people wish to pay as little as possible whilst hoping to derive maximum benefit from the purchase. In the case of medical schemes, this does however require a great deal of involvement from the member.

Longer lasting cover

The purpose maximising one’s benefits is to ensure they last longer and possibly cover more beneficiaries in the process. The following are some strategies that one can employ to preserve the benefits and derive more value from one’s current scheme. 

For hospitalisation or expensive procedures it is safer and mandatory by most schemes that you call in to get formal authorisation for the admission or procedure. The authorisation department validates the procedure codes against the diagnostic codes to ensure that members only pay for what is absolutely required for the procedure by national and international standards and guidelines. Members are encouraged to call in personally to get first hand information on any disclaimers and exclusions that may result in the member having to pay any excess.

Review and monitor statements

When consulting a doctor or any other service provider, always make a habit of understanding from which benefit the claim comes from. Review and monitor your claims statements closely in order to reconcile with the actual doctor visits and procedures and report any irregularities to the scheme. The scheme is not always in a position to determine what exactly transpired in the consultation room or hospital, and that is why the member needs to play an active role in protecting their benefits from such potential abuse.

It is not unreasonable to get a second opinion in cases where for some reason you are not at ease with the doctor’s diagnosis or treatment plan - particularly in serious and or expensive matters that require additional money from the member. The scheme may facilitate and even grant additional funding for a reasonable request for a second opinion. 

Negotiate discounts with service providers

It is only in the member’s interest to get into the habit of negotiating discounts with service providers in order to get more out of their given benefits. Negotiating discounts is particularly helpful in cases where doctors charge private rates, as most schemes only pay up to medical scheme rates and any excess often being for the members account.

Where possible; paying the service provider in cash and then claiming from the scheme is also a useful discount negotiating tool. Designated service providers (DSP’s) are preferred service providers with whom the scheme would have pre-negotiated huge discounts on behalf of the members. Utilising these DSPs is often a sure way of preserving your benefits.

Schemes may allocate additional benefits

Schemes may on written request allocate additional benefits in the form of what is known as ex-gratia funding. Enquire if your scheme has such a written policy so that you know when you may apply for such assistance. 

A common sense approach is to keep unexpired medicines in a safe cupboard. In cases where you have a minor health related concern, you may call your GP regarding the symptoms and mention to him what you have in your cupboard. In most cases doctors are happy to discuss such matters with their patients and may recommend what to take from the cupboard or may suggest that the patient comes in for examination. 

X-rays and laboratory results are the property of the patient. Before embarking on a new battery of medical tests, always inform your doctor where and when you had your recent tests. You are also entitled to all your clinical records from previous doctors. This makes life so much easier for your current doctor and may obviate the need for some tests and may reduce the number of required consultations.

Members should always be aware that the benefits allocated to them is indeed their own money and hence needs to be managed as such. A tendency to abuse benefits only results in an increase in contributions for the rest of the membership including oneself. It is possible to maximise ones benefits if one assumes a more active role in the interaction with service providers and the medical scheme. Schemes encourage and cooperate with members who are in managing their benefits.

(Dr James Arens, Clinical Operations Executive of Pro Sano Medical Scheme, October 2010)


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