Medical scheme tariff structures

There have always been two tariff structures in South Africa, according to which tariffs for medical treatments were determined. Then the Competitions Board stepped in, and in January 2004 the Department of Health issued a single guideline – the NRPL.

The first tariff structure is that of the Board of Healthcare Providers (BHF). Most medical aids base their payments to healthcare providers (doctors, dentists, hospitals etc.) on this structure.

If your medical aid pays only 80% of the BHF tariff for you to see your GP, and the BHF tariff is, say, R100, and that's what your GP charges, you will have to pay R20 of the bill yourself. If your GP charges R120, you will have to pay in R40. This means that your GP does not charge BHF rates and you have to pay the difference between BHF rates and the final bill.

The second tariff structure is that of the South African Medical Association (SAMA), which represents doctors in private practice. This association publishes an annual rates guide of what it thinks its members should be paid for their services. These rates are generally much higher than the BHF rates.

If your medical aid pays only 80% of BHF rates for visits to a specialist and the BHF rate is, say, R200, you will be paid out R160 by your medical aid. If the specialist charges R400, you will still be paid out R160. The remaining R240 will be for you to cough up. Obviously this depends on your individual medical aid itself, or the option you have chosen within it.

What is National Health Reference Price List (NHRPL)?

This is a price list for health services published by Council for Medical Schemes and is used to reimburse service providers.

Is a provider of a health care service entitled to charge more than the fees determined by medical schemes / the tariff specified in the NHRPL?

Yes. Health care providers are free to determine their own fees. Consequently, if an account is in excess of the fee determined by the rules of a medical scheme / NHRPL for a particular service, the difference is for the account of the member.

Understanding medical tariff “jargon”
More then ever one realizes that the Medical Scheme business is a complex one and there are so many “loopholes” of which individuals need to make sure. Ask questions, do research and make sure you can make an informed decision.

The Department of Health publishes tariffs and rules for specific health services or suppliers. These are the tariffs your medical scheme will cover for certain procedures.

NHRPL rates: The National Health Reference Price List, which is the guidelines of the Council of Medical Schemes’ (government).

The main difference between various schemes and options is the cover that you would have with regards to specialists and others suppliers, whilst hospitalized.

The 100%, 200% or 300% cover is for specialist visits and procedures within hospital. First choice will always be cover at 300% of the National Health Reference Price List (NHRPL). The Council for Medical Schemes compiles this list every year.

Where one chooses a scheme that only covers 100% of NHRPL, the patient will be responsible for the difference to be paid if the specialist charges more.

Keep in mind you’ve got rights too, take the responsibility to negotiate rates with your specialist beforehand, specifically before you are admitted for a certain procedure and the nurse take you through to the theatre.

Have the confidence to speak your mind, and make sure you are comfortable with the bill that is going to arrive in your post box. You can control this. And if your specialist is not willing to negotiate, make the choice either pay the difference or find somebody else. Regularly review your medical scheme option once a year during option renewal time, to make sure you are familiar with the benefits you are paying for.

According to Neville Koopowitz, CEO of Discovery Health, research into fees charged by specialists indicates that 45% charged fees at NHRPL rates, 20% on average 135%, 30% between 135% and 300%, and 5% over 300%.

If your scheme is only covering 100% of NHRPL, you ideally want to visit a specialist, which charge NHRPL rates (thus the 45% of specialists). Sometimes it is better paying slightly more for your medical aid per month, but you are covered at 300%.

Example of the above:
CT Scan (Brain Scan with contrast only)

- NHRPL rate (100%) covers R2575.90
- Medical Scheme (300%) covers R7727.70

Thus say for instance your specialist charge at 300% rates, and you are only covered at 100% (NHRPL rate) – you will need to pay the difference (R5151.80)

(Susan Erasmus, Health24 updated March 2009)

- Council for Medical Schemes
- Optivest Health Service
- Source Health Care in South Africa 2007

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