One of the tools used by medical aids to manage the costs of Prescribed Minimum Benefits (PMBs) is to contract with doctors to form a network of doctors. In exchange for a higher fee from the medical aid and, perhaps, other benefits like direct or more rapid payment, the doctor agrees not to charge a fee higher than that agreed to with the medical aid and to meet other requirements that the medical aid might want.
On the benefit side, the medical aid then requires of members that, in order for their non-emergency PMB claims to be paid in full the patient must use the services of one of these contracted doctors. This is called a Designated Service Provider (DSP) arrangement. This is legal and acceptable in terms of the PMB legislation and regulations. If a patient chooses to go to a non-DSP provider then the medical aid pays the claim at its usual rate and the member is liable for the difference between that rate and what the doctor has charged.
There are some provisos – the medical aid must ensure that there are DSP providers accessible to the patient at the time that they need the service and the need to use a DSP falls away in an emergency. Several PMB claims are only part paid because of “voluntary use of a non-DSP”.
A problem arises when it comes to anaesthetists. No patient going for surgery chooses their anaesthetist. It is always the surgeon that chooses the anaesthetist. Often the patient only meets the anaesthetist on the day of the surgery, very shortly before being wheeled into theatre. There is nothing voluntary about the use of service provider, whether a DSP or not.
Making matters worse is the unwillingness or inability of medical aids to identify exactly who their DSP anaesthetists are. It is a strongly held view that medical aids either have no or very few contracts with anaesthetists and that they cannot ensure the accessibility of DSP providers for anaesthesia.
Where surgery is performed for a bone fide PMB condition the anaesthetist should be paid in full, whether a DSP or not.
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