UPDATE: In July 2010 the National Health Reference Price List (NHRPL) was declared null and void by the Gauteng High Court. Currently prices are calculated according to the Reference Price List (RPL).
At some point in our lives, every one of us has to consider medical aid rates - whether it is when choosing which medical aid scheme will best meet our individual health needs, or when deciding which medical practitioner to consult or whether to ask for a generic medicine.
Understanding how medical aid tariffs are calculated can be difficult, particularly for people who are not familiar with medical aid jargon and acronyms such as BHF, NHRPL, ICD-10 and PMB, and MMAPÂ®. Each of these terms has a specific meaning that is useful to know when navigating information offered by medical practitioners and medical aid providers.
Medical aids pay out according to Medical Scheme Rates (MSR), which differ from scheme to scheme. The MSR of Selfmed's plans are set according to each plan's benefits and level of cover:
Until recently, South Africa had three tariff structures: the Board of Healthcare Funders (BHF) tariff list, the Health Professions Council of South Africa (HPCSA) ethical medical rates and the NHRPL. In January 2004 the BHF tariff was discarded, and in December 2008 the HPCSA stopped publishing its suggested rates; therefore, only NHRPL rates are currently used. Read on to learn more about how medical aid tariffs are regulated and to understand how this change affects you.
Until 2004, the BHF published its own list of recommended tariffs, which was compiled by means of negotiation between the BHF and the South African Medical Association.
The BHF list was ruled as being in contravention of the Competition Act, which regulates activities between businesses and organisations that should be competitors. Therefore, the BHF no longer publishes its list of recommended medical tariffs; the NHRPL rates have taken its place. According to BHF spokeswoman, Heidi Kruger, the BHF fully supports the process of determining the NHRPL tariffs.
The NHRPL was designed by the Council for Medical Schemes on behalf of the Department of Health, and was first published in 2004. This list does not contain negotiated prices; it is compiled by gathering submissions from all disciplines of health service with suggestions regarding the actual cost of running a practice.
Hospitals do not yet take part in the classification process; therefore, the NHRPL methodology of calculating its rates does not yet pertain to hospitals. Until the Hospital Association of South Africa and the Department of Health have reached consensus on the methodology that needs to be applied to calculate hospital tariffs, medical aid providers will negotiate with healthcare providers on an individual basis to decide on pricing.
The NHRPL does not always reflect the actual prices that may be charged at medical practices. Therefore, its rates are more of a guideline for practitioners and medical aid schemes around which they can calculate tariff structures and design benefit structures so as to minimise additional payments from insured members.
In the same way that doctors are not bound by the NHRPL, medical aid schemes are free to calculate their own MSR. Each medical aid scheme tends to use its own MSR, which is created using the NHRPL as guideline.
Historically, there was another list of published rates, which the HPCSA published: the so-called ethical medical tariffs. The HPCSA announced in November 2008 that it would do away with those tariffs and, in essence, scrap the publication of the list.
What remains is the NHRPL, which now is the de facto RPL.
The change in price regulation has had many repercussions throughout the medical and medical aid communities, but how does it affect consumers? The new system has undoubtedly filtered down to medical aid members.
There are two ways of paying a doctor or specialist if a patient has medical aid:
1. The medical aid provider can pay its MSR directly to the patient or member. In that case, the patient is responsible for paying the doctor the full amount for the procedure.
2. The medical aid provider can pay the doctor directly. In that case, the patient or member will be expected to contribute financially only if the doctor's fees exceed the provider's contribution.
Medical aid providers are now unable to predict exactly what a doctor will charge for a specific procedure; consequently, they generally formulate the cover they offer by referring to their MSR. If a particular medical aid scheme provides members with 200% of its MSR and the doctor charges the same amount or less, the patient is completely covered. If, however, the medical practitioner charges 250% of the particular scheme's MSR, the patient must pay the difference from his or her own pocket.
ICD-10 codes are used internationally to diagnose and classify diseases and medical ailments. All conditions are categorised according to their specific symptoms. ICD-10 codes are designed to keep doctor's diagnoses consistent and easily identifiable by other medical practitioners and medical aid providers.
When an individual signs up for a particular medical aid scheme, the medical aid provider agrees to contribute financially towards treatment of a certain selection of ailments and illnesses. ICD-10 codes provide a reliable way to describe any illness or ailment, and supply medical aid providers with accurate information to help them know how much to pay out. Medical aid providers are required by law to submit the ICD-10 code with every claim.
This list is particularly helpful for medical aid scheme members who suffer from ailments for which Prescribed Minimum Benefits (PMBs) are applicable. These are health issues that medical aid providers are required by law to cover for all their members, regardless of the medical aid plan any individual member subscribes to.
Maximum Medical Aid Price (MMAPÂ®) is a pricing reference model for pharmaceutical products. The MMAP listing is owned and maintained by Medikredit and guides the maximum amount medical schemes will pay for interchangeable multi-source pharmaceutical products (generics).
Deciding which medical aid scheme suits your health requirements best is one of the most important decisions that you can make in your life. It may seem inconsequential now, but it can provide you with immense peace of mind should the unforeseen occur. It is imperative that you understand exactly what your medical aid provider will contribute towards your treatment. Selfmed Medical Aid Scheme strives to provide sincere, ethical and secure medical aid cover to all its members. In general, Selfmed has a 100-200% MSR rate on many of its medical aid options. Make sure that you understand each plan and regularly review the cover you have bought to ensure that you are covered sufficiently for your particular circumstances.