Also see Consultation Information
History of the Medical Aid Rate
Previously, doctors based their tariffs and billing policy on what was known as the “Reference Price List”. This also became known as the “medical aid rate” as it is the lowest rate that medical schemes were legally allowed to cover. Some schemes had their own rates which were higher than the RPL. Billing systems determine the tariff by multiplying the “clinical units” for a procedure by the RPL rate (or another rate). The number of clinical units that a procedure is worth is dependent on the complexity and potential time that the procedure would entail. This has been defined by the South African Medical Association (SAMA) in the doctors billing manual (DBM).
The End of the Medical Aid Rate
On the 28th of July 2010, Judge Piet Ebersohn declared the RPL 2007 – 2009 null and void. He found the process by which the RPL rates were determined to be “unfair, unlawful, unreasonable and irrational”. The Judge also said that the process resulted in tariffs that were “unreasonably low” and cited this as one of the reasons for the exodus of doctors from the country.
What the Judge effectively did was declare the “Medical Aid Rate” illegal. Presently this allows doctors to bill at any rate, but it also allows medical aid schemes to cover their members at any rate. Disputes are inevitable and a process is underway to provide a new framework.
My Practice Billing Policy for Reconstructive Surgery
In the interim doctors have to decide on what rate they will bill and inform their patients about it.
My practice billing policy is to charge at the Discovery Classic Direct Rate which is less than the private rate.
I am a Discovery Health contracted doctor and I consider this rate as reasonable. This rate will be covered fully by some schemes, while others will require a co-payment on the part of the patient. Co-payment will be determined by the benefits applicable to the particular scheme to which a patient belongs. In certain cases, where the patient’s diagnosis is part of the Prescribed Minimum Benefit (PMB), the cost of the surgery may be covered in full if the patient follows the rules required by South African Law as well as the regulations of their scheme. For more information :
What to do if you have a PMB diagnosis, Click Here.
To view the PMB Legislation, Click Here.
My Practice Policy for Aesthetic Medicine and Surgery
For these procedures, there is no third party payments and the full responsibility for the costs of the procedure rests with the patient. There is no lawful way to “claim” against a third party insurance or medical benefit scheme even ad hoc. All surgical procedures must be paid in full prior to the patient’s admission to hospital. All rooms procedures must be paid in full on the day of the procedure. I do not offer any installment options or in-house finance, but refer patients to registered credit providers in this regard.