Why you should stick to designated service providers

IN AN EFFORT to ensure quality service in the face of medical inflation, many medical aid schemes have implemented networks of designated service providers (DSPs).

This helps control costs and means medical aids can offer discounted plans restricting members to these networks.

For members, this means that should you use a DSP, treatment will generally be covered in full, especially for prescribed minimum benefit (PMB) conditions. However, there are often penalties involved when using a non-DSP. Understanding how DSPs work and how gap cover can help is critical to making the most of your medical aid coverage.

DSPs are health-care providers, including hospitals, doctors and pharmacies, contracted within your medical aid scheme as preferred service providers with the agreement to charge agreed rates for services.

Members have access to medical care that is fully covered, while healthcare providers benefit from increased patient volumes. They also often have a direct payment arrangement with the medical aid, which means the patient doesn’t have to pay the medical provider upfront. Moreover, service providers receive prompt payment.

DSP networks also extend to out of hospital treatment or care at pharmacies for chronic medication, where members need to make use of specific pharmacies to obtain medication.

Members can be penalised financially for obtaining chronic medication from a non-DSP pharmacy. By using DSPs, you can avoid medical expense shortfalls for PMB conditions and avoid penalties and co-payments for treatment and medication.

There are specific instances where your medical aid will fund the use of a non-DSP in full for PMB conditions. For example, if a DSP is not available to assist within a reasonable time frame, such as if a patient requires a heart bypass in hospital and the DSP for the medical aid is away, then a non-DSP will be covered due to the urgency.

The act states that if immediate treatment for a PMB condition is required under circumstances or at locations where the beneficiary can’t obtain treatment from a DSP, this will be covered. Furthermore, if there’s no DSP within reasonable proximity to the beneficiary’s ordinary place of business or personal residence, a PMB will be covered in full at a non-DSP.

While these circumstances will be covered, it is important to remember that once your condition has stabilised or a DSP becomes available, your medical scheme may request you to make use of a DSP for further treatment.

When you require a medical procedure, you may do all of the required work to ensure you make use of a DSP specialist at a DSP hospital, only to find on the day of your surgery, for example, that the anaesthetist preferred by your surgeon is not a DSP.

This means that you’ll be liable for the medical expense shortfall in payment to this doctor. Gap Cover can help minimise this shortfall.

Your preference can also play a huge role in determining your choice of provider. You might have a gynaecologist who has treated you for years, and when you fall pregnant you’d like the same gynaecologist to deliver your baby. However, this doctor might not be a DSP. You might choose to stay with a service provider due to your existing relationship with them, which means that you will be liable for any medical expense shortfalls, if you do not have Gap Cover in place.

For a non-PMB condition, making use of a non-DSP can incur significant penalties. Most specialists charge above the scheme rate and without gap cover you will have to pay.

It is important to discuss your medical aid and gap cover needs with your financial adviser to make sure you know who falls within your DSP network and how to access them. Cover for non-DSPs is not a standard Gap Cover benefit and non-DSP hospital penalty cover is often a limited benefit.

Having a Gap Cover provider who understands it’s not always possible to use a DSPs is essential. Your financial adviser can ensure you have the most appropriate options.