ADVICE FOR MEMBERS
• 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.