AD­VICE FOR MEM­BERS

Weekend Argus (Saturday Edition) - - FRONT PAGE -

• If your med­i­cal scheme op­tion re­quires you to use a des­ig­nated ser­vice provider (DSP), or doc­tors or hos­pi­tals that be­long to a net­work, and you don’t like the providers cho­sen on your be­half, you can at year-end change to an op­tion that gives you greater free­dom of choice. But this will re­sult in you pay­ing higher con­tri­bu­tions. • If your fam­ily doc­tor does not be­long to the net­work that you are re­quired to use, ask him or her why. Some doc­tors are op­posed to net­works, be­cause they al­legedly in­ter­fere with the au­ton­omy of med­i­cal prac­ti­tion­ers. Although your doc­tor may be un­will­ing to ne­go­ti­ate tar­iffs with your med­i­cal scheme, he or she might be will­ing to ne­go­ti­ate a lower fee di­rectly with you. • Most mem­bers do not have the data or in­sight to sec­ond guess whether their scheme has se­lected the most ap­pro­pri­ate DSP. How­ever, you can com­plain to the Coun­cil for Med­i­cal Schemes (CMS) if the DSP is a long way from your home or place of work. The CMS may ask your scheme to add a provider that is more con­ve­nient for you. • If your scheme changes its DSPs in the mid­dle of the year, you can com­plain to the CMS, be­cause it is a ma­te­rial change to the terms of the con­tract be­tween you and your scheme, par­tic­u­larly if the change ad­versely af­fects your abil­ity to ac­cess health care. The CMS can or­der the scheme to en­sure that you are not de­nied ac­cess to health­care ser­vices. • Paresh Prema, the gen­eral man­ager: ben­e­fits man­age­ment at the CMS, says mem­bers should be proac­tive. If a sur­geon recommends that you or a fam­ily mem­ber un­dergo an elec­tive pro­ce­dure, ask your med­i­cal scheme how much of the cost it will cover be­fore you ask for preau­tho­ri­sa­tion. You can use the in­for­ma­tion to ne­go­ti­ate with the sur­geon over his or her fee. In most cases, sur­geons are pre­pared to be flex­i­ble over the fee if it is cer­tain what the scheme will pay, he says.

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