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It has become an all too familiar scenario in South Africa. Medical aid members are surprised to find that there are outstanding medical bills even after the scheme pays the providers. Often it is the doctor’s bill that is not paid completely. However, the problem does not lie with the medical aid. It is the onus of the patient to pay the shortfall out of his/her own pocket or by the means of medical gap cover. Failure to make up for the difference can mean dealing with lawyers, debt collectors and even the credit bureau.

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Speak to the Gynaecologist and Anaesthetist

One of the most important steps in avoiding shortfalls in medical aid payments for pregnancy and childbirth is to speak to the service providers involved. First and foremost you should start with the medical doctors who will be monitory your pregnancy and assisting with childbirth. This is your obstetrician and gynaecologist, but if you are planning an epidural or Caesarean section (C-section) then this also involves an anaesthetist. Your obstetrician-gynaecologist (OB-GYN) will usually select and anaesthetist that he/she prefers.

Private hospitals usually keep bills with medical aid tariffs so shortfalls are unlikely. At most it may be a small amount above and beyond what your medical aid will pay. However, with more medical specialists now charging private or SAMA rates you will often find that your OB-GYN and/or anaesthetist will not accept medical aid or demand a co-payment from you after they are settled by the medical aid. It is therefore important to understand what you may be liable for during your pregnancy and after childbirth.

Some Medical Aid Pay Higher Rates

Some schemes, and specifically on certain plans, will cover higher rates by the doctor, specialist or other service provider. They may cover 200% or even 300% of the regular medical aid rate if this is what your doctor demands. However, these plans are usually much more expensive. It is important to know if you are covered by such a plan right at the outset of the pregnancy. Do not expect it to be automatically granted just because you are a medical aid member and pay your premiums.

Many medical aid members now prefer to have separate medical gap cover. It is not part of your medical aid but covers a range of conditions, including maternity benefits. Gap cover is a type of insurance that will pay the difference above and beyond what your medical aid pays, but up to a certain limit. While you medical aid will settle its tariff, the gap cover will pay the difference thereafter. Many doctors will allow patients to claim from their gap cover and settle the bill within a specific period of time rather than demanding it immediately, provided that they have gap cover.

Shortfalls for Other Reasons

Shortfalls in what your medical aid pays to service providers is not always due to doctors charging higher rates. Your medical aid may have policies in place not to pay certain procedures, either in part or fully, as per the plan option. This is commonly seen with expensive diagnostic investigation like MRI scans these day. It is important to clarify with your medical aid why the shortfall has occurred. Sometimes the scheme has paid in full as per their tariffs but the service provider charges more. At other times the medical aid has not paid in full.

Apart from individual restrictions the other common issue that arises is exhausted benefits. Medical aid members are well aware that their benefits do not go as far as it previously did. And it is rapidly shrinking everyday as private healthcare costs rise and medical schemes are under financial pressure. Irrespective of the reason, the patient is then liable for the shortfall and has to settle the difference in full with the doctor, laboratory, pharmacy or hospital.