It is sometimes confusing when comparing different types of hospital plans. Most seem the same and cost around the same price. However, when you are looking at a medical aid hospital plan it is important to take note of whether the plan covers private rates for doctors and specialists. Healthcare is confusing enough with all the medical jargon and then the talk of different rates for medical services often means that patients are lost and just go with what the doctor or medical aid says. However, the shock comes when you have to top up the doctor’s bill at the end of your hospital stay.
What does private rates mean?
The term private rates can be a bit confusing but it simply means that your doctor charges above the medical scheme rates which are determined by the NHRPL (National Health Reference Price List) that is updated annually. There is no point in arguing why some doctors charge private rates and others do not. The bottom line is that private practitioners are allowed to charge the rate they wish. Whether patients are prepared to pay these rates is another story altogether.
A doctor may say that they charge private rates or SAMA / MASA rates. This does not mean that you medical aid pays these rates. However, patients are more likely to face this dilemma when it comes to medical specialists and sometimes the auxiliary health care providers like clinical psychologists. When you are in hospital, these private rates can be a major financial blow especially if you are undergoing a surgical procedure.
For example, the NHRPL rate may be around R 600.00 for a tonsillectomy (surgical removal of the tonsils) but the ENT (ear, nose and throat) surgeon may charge R2,000.00 for the procedure. If you medical aid states that it pays 100% of NHRPL then it means that the scheme will only cover R 600.00 for the surgeon’s fees. You pay the surgeon the other R1,400 from your own pocket.
Plans That Pay Private Rates
Fortunately there is some protection for medical aid members. Many medical aid hospital plans are now available on the market that will pay 150%, 200% or even up to 300% of the NHRPL. This means that your medical aid will pay one and a half times, two times or even three times the NHRPL rate to your doctor or specialist. Hospitals usually do not charge above the NHRPL so it is the doctor’s fees that is of greater concern.
However, medical aid members should not be lulled into a false sense of security by the supposed protection offered by their medical aid. Remember that this is private rate is usually only covered when you are in hospital and seen, treated or operated upon by the doctor or specialist. If you see your doctor or specialist on an out-patient basis in their consulting rooms then you will have to pay the difference in cash.
Contracted Out of Medical Aid
Many doctors and specialists who do charge private rates are often not contracted into medical aid. This means that they will not claim directly from the scheme and will not be reimbursed directly by your medical aid. In other words the doctor may give you the bill and you will then have to claim. Many doctors and specialists who are contracted out of medical aids are gracious enough to give you leeway to pay them back once the scheme pays you. Others are not and expect payment upfront while you can expect to get reimbursed by your medical aid at a later stage.
Private Hospital Rates
It is important to iron out all these details with both your doctor and the medical aid before you go into hospital or be wheeled into the operating theatre. Some procedures, like a heart valve replacement or coronary artery bypass surgery, can costs in the tens of thousands of rands. Should your medical aid hospital plan not cover above the NHRPL as per the doctor’s private rates, then you may be forking out a large sum while you are incapacitated and recovering from a life threatening situation. There is no recourse for the patient as you are expected as a medical aid member to be aware of these differences in pricing between the NHRPL and the private rate the doctor commands.
These private hospital rates are not only applicable to certain medical specialities. These days almost all medical specialists are charge private rates, even obstetricians and gynaecologists as well as paediatricians. You may have a hospital plan medical aid for pregnancy and think that you are well covered for the medical expenses but can be surprised with the bill you are landed with after you are discharged. It is more likely to be higher if you had a C-section, complications while in labour and during childbirth, or if you baby has congenital (birth) defects or is preterm and needs to spend a few weeks in the neonatal ICU.